Metropolitan Assisted Living LLC

Based on the record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services for two of two caregivers sampled. The deficient practice posed a risk if the employees did not have the skills and knowledge required to ensure the health and safety of residents. Findings include: 1. A review of E2's and E3’s personnel records revealed no documented verification of E2's and E3's skills and knowledge. 2. In an interview, E1 acknowledged E2’s and E3’s personnel records did not include documented verification of skills and knowledge at the time of the survey.

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 one of two 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 R2's medical records revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance dates, this documentation was required. 2. In an interview, E1 acknowledged R2’s medical record did not contain documentation that stated whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints.

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested to review the facility's fall prevention and fall recovery training program. However, a fall prevention and fall recovery training program was not available for review. 2. A review of E3's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 7. In an interview, E1 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(A), for one of three employees sampled. The deficient practice posed a risk if E4 was a danger to a vulnerable population, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E4's (hired in 2021) personnel record revealed a copy of E4's fingerprint clearance card. The card was issued on January 20, 2017 and expired on January 20, 2023. 2. A review of the Arizona Department of Public Safety fingerprint verification website revealed E4's card was issued on January 20, 2017 and expired on January 20, 2023. 3. In an interview, E1 acknowledged E4's fingerprint clearance card had expired.

Based on observation, 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. The deficient practice posed a risk as E1 was not present on the premises and accountable when E3 was not present on the premises, the Department was unable to determine substantial compliance as documentation designating E2 was not available during the inspection, and the documentation was not provided within two hours after a Department's request. Findings include: 1. The Compliance Officer observed E2 on the premises and working when the Compliance Officer arrived at approximately 11:45 AM. 2. The Compliance Officer observed a document titled "MANAGER'S DESIGNEE" (dated August 8, 2021) posted on a bulletin board, located near the kitchen. The document stated "ADHS States that a facility manager designates in writing, one or more individuals who are 21 years of age and older who meet the qualifications for caregiver in as the manager designee. A manager designee is physically present at the facility and in charge of the assisted living facility operations when the manager is not physically present.' [sic]" The document was signed by E1 and E3. However, documentation designating E2 to be present on the premises and accountable for the assisted living facility when E3 was not present on the premises was not available for review. 3. A review of the facility's policies and procedures revealed a policy titled "DELEGATION OF AUTHORITY" (dated July 15, 2021). The policy stated "...The assisted living facility manager shall delegate in writing one or more individuals who are 21 years of age or older who meet the qualifications for a caregiver as the manager designee." However, a designated caregiver was not identified. 4. The Compliance Officer requested to review E1's and E2's personnel records. However, E1's and E2's personnel records were not provided for review. 5. In an interview, E1 acknowledged a designated individual was not present on the premises when the manager was not present on the premises.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident covering cardiopulmonary resuscitation (CPR) training, including a demonstration of the employee's ability to perform CPR. The deficient practice posed a risk as policies and procedures reinforce and clarify standards, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "CPR AND FIRST AID" (dated July 15, 2021). The policy stated "...Employees and volunteers shall provide documentation of CPR...and First Aid Training, to include the method and content of the training which includes a demonstration of the caregiver's ability to perform CPR...The Owner and/or Manager shall ensure that all employees and volunteers that require CPR and First Aid training renew their certificates /Cards in a timely manner prior to the expiration date...CPR and First aid shall not be obtained from on line courses." 2. A review of E3's (hired in 2021) personnel record revealed E3 was hired as the manager. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued January 22, 2020). 3. A review of the NationalCPRFoundation website revealed courses are conducted online. The NationalCPRFoundation website stated, "Help Save Lives Today with Your Online CPR Certification Training!" 4. In an interview, E1 acknowledged E3's expired online CPR training did not include a demonstration of E3's ability to perform CPR.

Based on documentation review, record reviewand interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of E4's personnel record revealed a copy of E4's fingerprint clearance card. The card was issued on January 20, 2017 and expired on January 20, 2023. 2. The Compliance Officer observed a document titled "MANAGER'S DESIGNEE" (dated August 8, 2021) posted on a bulletin board, located near the kitchen. The document stated "ADHS States that a facility manager designates in writing, one or more individuals who are 21 years of age and older who meet the qualifications for caregiver in as the manager designee. A manager designee is physically present at the facility and in charge of the assisted living facility operations when the manager is not physically present.' [sic]" The document was signed by E1 and E3. However, documentation designating E2 to be present on the premises and accountable for the assisted living facility when E4 was not present on the premises was not available for review. 3. A review of E3's personnel record revealed E3 was hired as the manager. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued January 22, 2020). However, the CPR training did not include a demonstration of E3's ability to perform CPR. 4. A review of E4's personnel record revealed documentation of the verification of E4's skills and knowledge was not available for review. 5. A review of E5's personnel record revealed a hire date in June 2021. However, the ending date of employment was not available for review. 6. A review of E3's personnel record revealed documentation of evidence of freedom from infectious TB dated in 2021. However, current documentation of evidence of freedom from infectious TB was not available for review. 7. The Compliance Officer requested to review E1's and E2's personnel records. However, E1's and E2's personnel records were not provided for review. 8. A review of R4's medical record revealed evidence of freedom of infectious TB was not available for review. 9. A review of R3's medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 10. A review of R4's medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 11. A review of R1's medical record revealed a service plan dated in

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, and according to policies and procedures; for one of two current caregivers who had a personnel record sampled. The deficient practice posed a risk if E4 was unable to meet a residents needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "APPLICANT AND EMPLOYEE REQUIREMENT" (dated July 15, 2021). The policy stated "...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for." 2. A review of E4's (hired in 2021 as a caregiver) personnel record revealed documentation of the verification of E4's skills and knowledge was not available for review. 3. In an interview, E1 acknowledged E4's skills and knowledge were not verified and documented prior to E4 providing physical health services and according to the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training, for one of three employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency or an accident, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E3's (hired in 2021) personnel record revealed E3 was hired as the manager. The personnel record revealed documentation of CPR training from NationalCPRFoundation (issued January 22, 2020). 2. A review of the NationalCPRFoundation website revealed courses are conducted online. The NationalCPRFoundation website stated, "Help Save Lives Today with Your Online CPR Certification Training!" 3. In an interview, E1 acknowledged E3's expired online CPR training did not include a demonstration of E3's ability to perform CPR.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's ending date of employment, for one of three personnel records sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E5's personnel record revealed a hire date in June 2021. However, the ending date of employment was not available for review. 2. In an interview, E1 reported E5 does not work at AL11927. E1 reported E5 stopped working at AL11927 in 2022. 3. In an interview, E1 acknowledged E5's personnel record did not include the ending date of employment.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for one of three employees sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of E3's (hired in 2021) personnel record revealed documentation of evidence of freedom from infectious TB dated in 2021. However, current documentation of evidence of freedom from infectious TB was not available for review. 2. In an interview, E1 acknowledged E3's current documentation of evidence of freedom from infectious TB was not available for review.

Based on observation and interview, the manager failed to ensure a personnel record for an employee or volunteer was maintained throughout the individual's period of providing services in or for the assisted living facility. The deficient practice posed a risk as required information could not be verified for E1 and E2, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer observed E2 working on the premises upon arrival at approximately 11:45 AM. 2. The Compliance Officer requested to review E1's and E2's personnel records. However, E1's and E2's personnel records were not provided for review. 3. In an interview, E1 reported E1's and E2's personnel records were at a different location. 4. In an interview, E1 acknowledged E1's and E2's personnel records were not available for review.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB), before or within seven calendar days aftef the resident's date of occupancy, for one of five residents sampled. The deficient practice posed a TB exposure risk to residents, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R4's (admitted in 2023) medical record revealed evidence of freedom of infectious TB was not available for review. 2. In an interview, E1 acknowledged R4's evidence of freedom from infectious TB was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for two of five residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R3's (admitted in 2023) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 2. A review of R4's (admitted in 2023) medical record revealed documentation to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review. 3. In an interview, E1 acknowledged documentation to include whether R3 and R4 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

Based on record review and interview, the manager failed to ensure a resident had a written service plan developed with assistance and review from the resident or resident's representative, for one of five residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan dated in February 2023, for personal care services. However, the service plan did not include the signature of R1 or R1's representative to show the service plan was developed with assistance and review by R1 or R1's representative. 2. In an interview, E1 acknowledged the service plan for R1 was not signed to indicate the service plan was developed with assistance and review by R1's representative.

Based on record review and interview, the manager failed to ensure a resident had a written service plan developed with assistance and review from the manager, for two of five residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan dated in February 2023, for personal care services. However, the service plan did not include the signature of the manager to show the service plan was developed with assistance and reviewed by the manager was not available for review. 2. A review of R5's medical record revealed a service plan dated in April 2023, for personal care servicesHowever, the service plan did not include the signature of the manager to show the service plan was developed with assistance and reviewed by the manager was not available for review. 3. In an interview, E1 acknowledged R1's and R5's services plans were not signed to indicate the service plans were developed with assistance and review from the manager.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of five residents sampled who received personal care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's (admitted 2022) medical record revealed a service plan dated in November 2022, for personal care services. However, a reviewed and updated service plan was not available for review. 2. In an interview, E1 reported R2's updated service plan was completed. However, an updated service plan was not available for review. E1 acknowledged R2 received personal care services and the service plan was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided in the resident's medical records, for five of five residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan (dated in February 2023) for personal care services. The service plan stated the following services were to be provided to R1: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 2. A review of R1's medical record revealed an activities of daily living document for March 1-31, 2023. However, the following services were not documented as provided from April 1-30, 2023 to May 1-15, 2023: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 3. A review of R2's medical record revealed a service plan (dated in November 2022) for personal care services. The service plan stated the following services were to be provided to R2: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 4. A review of R2's medical record revealed an activities of daily living document for April 1-30, 2023. However, the following services were not documented as provided on May 1-15, 2023: -Bathing; -Dressing; -Grooming; -Hygiene; -Skin Care; -Toileting; and -Mobility. 5. A review of R3's medical record revealed a service plan (dated in April 2023) for personal care services. The service plan stated the following services were to be provided to R3: -Bathing; -Dressing; -Skin Care; and -Mobility. 6. A review of R3's medical record revealed an activities of daily living document for April 1-30, 2023. However, the following services were not documented as provided on May 1-15, 2023: -Bathing; -Dressing; -Skin Care; and -Mobility. 7. A review of R4's medical record revealed a service plan (dated in February 2023) for personal care services. The service plan stated the following services were to be provided to R4: -Bathing; -Dressing; -Hygiene; -Skin Care; -Toileting; and -Mobility. 8. A review of R4's medical record revealed an activities of daily living document for April 1-30, 2023. However, the following services were not documented as provided on May 1-15, 2023: -Bathing; -Dressing; -Hygiene; -Skin Care; -Toileting; and -Mobility. 9. A review of R5's medical record revealed a service plan (dated in April 2023) for personal care services. The service plan stated the following services were to be provided to R5: -Bathing; -Dressing; -Hygiene; -Skin Care; and -Toileting. 10. A review of R5's medical record revealed an activities of daily living document for April 1-30, 2023. However, the following services were not documented as provided on May 1-15

Based on record review, documentation review, observation and interview, the manager failed to ensure the resident's medical record included documentation of medication administration, for five of five residents sampled who received medication administration. The deficient practice posed a risk as medication administered could not be verified against a medication order, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's (admitted in 2022) medical record revealed a service plan (dated in February 2023). A review of the service plan revealed R1 received medication administration. 2. A review of R1's medical record revealed medication orders. 3. A review of facility documentation and R1's medical record revealed a medication administration record (MAR) for R1 was not available for review. 4. The Compliance Officer observed medications for R1. 5. A review of R2's (admitted in 2022) medical record revealed a service plan (dated in November 2022). A review of the service plan revealed R2 received medication administration. 6. A review of R2's medical record revealed medication orders. 7. A review of facility documentation and R2's medical record revealed a MAR for R2 was not available for review. 8. The Compliance Officer observed medications for R2. 9. A review of R3's (admitted in 2023) medical record revealed a service plan (dated in April 2023). A review of the service plan revealed R3 received medication administration. 10. A review of R3's medical record revealed medication orders. 11. A review of facility documentation and R3's medical record revealed a MAR for R3 was not available for review. 12. The Compliance Officer observed medications for R3. 13. A review of R4's (admitted in 2023) medical record revealed a service plan (dated in February 2023). A review of the service plan revealed R4 received medication administration. 14. A review of R4's medical record revealed medication orders. 15. A review of facility documentation and R4's medical record revealed a MAR for R4 was not available for review. 16. The Compliance Officer observed medications for R4. 17. A review of R5's (admitted in 2023) medical record revealed a service plan (dated in April 2023). A review of the service plan revealed R5 received medication administration. 18. A review of R5's medical record revealed medication orders. 19. A review of facility documentation and R5's medical record revealed a MAR for R5 was not available for review. 20. The Compliance Officer observed medications for R5. 21. In an interview, E1 reported E1 was in the process of moving the MAR's to an electronic medical record platform. However, documentation of the MAR's were not available for review. 22. In an interview, E1 acknowledged R1's, R2's, R3's, R4's, and R5's medical record did not include documentation of medication administered to R1, R2

Based on record review and interview, the manager retained a resident without meeting the requirements in R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one resident sampled who was confined to a bed or chair because of an inability to ambulate even with assistance. The deficient practice posed a risk if the facility was unable to meet a resident's needs, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed a service plan (dated in November 2022) for personal care services. The service plan stated "ASSISTIVE DEVICES: Wheelchair...Bedbound...AMBULATION: NON-AMBULATORY..." 2. A review of R2's medical record revealed a document titled "DETERMINATION FOR CONTINUED RESIDENCY" (dated in November 2022). The form was signed by a medical practitioner. 3. A review of R2's medical record revealed a document titled "APPROVAL OF CONTINUED RESIDENCY" (dated in November 2022). The form was signed by a medical practitioner. However, documentation of an examination at least once every six months signed and dated by the resident's primary care provider or other medical practitioner was not available for review. 4. In an interview, E1 reported R2 was ambulatory. E1 acknowledged the examination required from the resident's primary care provider or other medical practitioner every six months during R2's residency was not available for review.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of Department documentation revealed AL11927 license was effective on August 25, 2021. 2. A review of facility documentation revealed documentation of evacuation drills were not available for review. 3. In an interview, E1 acknowledged documentation of evacuation drills were not available for review.