Mom and Dad Solutions Assisted Living LLC

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management". This policy stated "...1) An Assurance Checklist will be performed by the manager/caregiver/designee on a regular basis and at least once every 3 months..." 2. The Compliance Officer requested to review the facility's quality management reports submitted to the governing authority. However, the reporters were not provided for review. 3. In an interview, E1 and E2 acknowledged the quality assurance program had not been implemented.

Based on documentation review, record review, and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of three employees reviewed. The deficient practice posed a potential 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E3's personnel record revealed no evidence of freedom from infectious tuberculosis on or before the date of hire. 4. In an interview, E1 and E2 acknowledged E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

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 three of three 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 R1's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R1 had signs or symptoms of TB. Based on R1's date of acceptance, this documentation was required. 3. A review of R2's medical record revealed no documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. Based on R2's date of acceptance, this documentation was required. 4. 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. 5. In an interview, E1 and E2 acknowledged R1, R2, and R3's medical records did not include documentation of a risk assessment of prior exposure to infectious TB or a determination if they had signs or symptoms of TB.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza( flu) and pneumonia according to A.R.S. § 36-406(1)(d), which required the facility to make the vaccinations available to the resident on site on a yearly basis; for one of two sampled residents' records that were reviewed who had resided at the assisted living facility for more than 12 months. 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. A review of R1's medical record did not include documentation to indicate the vaccines were offered, given, or refused. Based on R1's acceptance date, this documentation was required. 3. During an interview, E1 and E2 acknowledged R1's medical record did not include documentation showing the flu and pneumonia vaccines were offered or received.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements of R9-10-814(B)(2)(b)(iii), for two of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. R9-10-814(B)(2)(b)(iii) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: the resident's primary care provider... examines the resident... at least once every six months throughout the duration of the resident's condition; reviews the assisted living facility's scope of services; and signs and dates a determination stating that the resident's needs can be met by the assisted living facility..." 2. A review of R1's service plan (dated April 1, 2025) revealed R1 received directed care services, and was confined to a bed or chair. 3. A review of R1's medical record revealed documentation of the determination required dated March 1, 2024. However, additional documentation signed by R1's primary care provider was not available for review. 4. A review of R2's service plan revealed R2 received directed care services and was confined to a bed or chair. 5. A review of R2's medical record revealed documentation of the determination required dated April 4, 2024. However, additional documentation signed by R2's primary care provider was not available for review. 6. In an interview, E1 and E2 acknowledged the facility did not obtain a written determination from R1's and R2's medical practitioners every six months as required.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a bottle of "Fantastik Bleach", "Great Value Disinfectant Spray", and an open container of "Comet Cleansing Powder" in an unlocked cabinet under the kitchen sink. The Compliance Officer also observed a bottle of "Clorox Toilet Bowl Cleaner" and a can of "Scrubbing Bubbles Bathroom Grime Fighter" in an unlocked cabinet under the bathroom sink. 2. In an interview, E1 and E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents.

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. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of facility documentation revealed a policy regarding fall prevention and fall recovery. However, the policy did not include the initial training and continued competency requirement. 2. A review of E1's and E2's personnel records revealed documentation a fall prevention training had been conducted in May 2022 by a third party. 3. In an interview, E1 and E2 acknowledged the facility had not developed a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency. This is a repeat deficiency from the compliance inspection conducted on May 16, 2022.

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 to cover in-service education for employees and volunteers. Findings include: R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer. 1. A review of facility documentation revealed a policy and procedure titled "Employee Orientation & Ongoing Training" (dated in 2019). The policy and procedure stated, "The manager/owner of the facility shall ensure that each caregiver and manager completes a minimum of 6 hours of Supervisory and Personal Care and another 6 hours of Directed/Behavioral care related topics of ongoing training every 12 months from the starting date of employment." 2. A review of E2's (hired in December 2019) personnel record revealed a certificate dated May 20, 2022. The certificate stated, "Topic: Duty of Care... 3.0 Hours..." However, additional documentation of completing in-service education during the calendar year of December 2021 to December 2022 was not available. 3. In an interview, E1 and E2 acknowledged E2's personnel record did not include documentation of completing 12 hours of in-service education, as required by the facility's policies and procedures.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. Findings include: 1. A review of Department documentation revealed the license for AL11295 was effective in 2019. 2. A review of facility documentation revealed a policy and procedure manual dated in 2019. However, documentation to indicate the policy and procedure manual had been reviewed and updated at least once every three years was not available for review. 3. In an interview, E1 and E2 acknowledged the policies and procedures had not been reviewed at least once every three years.

Based on documentation review, record review, and interview, the manager failed to ensure the facility's residency agreements contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for two of two residents sampled. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: R9-10-807(C): A manager shall not accept or retain an individual if: 1. The individual requires continuous: a. Medical services; b. Nursing services, unless the assisted living facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; 2. The primary condition for which the individual needs assisted living services is a behavioral health issue; 3. The services needed by the individual are not within the assisted living facility's scope of services and a home health agency or hospice service agency is not involved in the care of the individual; 4. The assisted living facility does not have the ability to provide the assisted living services needed by the individual; or 5. The individual requires restraints, including the use of bedrails. 1. A review of facility documentation revealed a policy and procedure titled "Termination of Residency" (dated in 2019). The policy and procedure stated, "A. The Administrator may terminate residency of a resident as follows: 1. Without notice, if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in an assisted living facility; 2. With a 14 calendar day written notice of termination of residency: a. For nonpayment of fees, charges, or deposits; or b. Under any of the conditions in subsection (C); or 3. With a 30 calendar day written notice of termination of residency, for any other reason." 2. A review of R1's and R2's medical records revealed residency agreements. The residency agreements stated, " 2. The home may terminate a resident's residency agreement after providing fourteen (14) days written notice to a resident or the resident's representative for one of the following reasons; a) Documentation of failure to pay fees or charges, deposits; b) The individual requires continuous medical services, nursing services (unless the facility complies with A.R.S. \'a7 36-401(C); or c. Behavioral health services; d) The assisted living services needed by the individual are not within the assisted living facility's scope of services; e) The individual requires restraints, including the use of bedrails." 3. In an interview, E1 and E2 acknowledged R1's and R2's residency agreements did not include the correct provisions for an assisted living facility to terminate residency with a fourteen-day written notice which was required to include the primary condition for which the individual needs assisted living services is a behavioral health issue and a home health agency or hospice service agency is not involved in the care of the individual.

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 one of two residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan (dated in April 2023) for personal care services. The service plan stated R1 was to receive partial baths on the days when complete baths were not given. 2. A review of R1's medical record revealed an activities of daily living (ADL) log for June 2023. The ADL revealed the following: - Complete baths were documented as given on June 2, 5, 7, 9, 11, 13, 16, 19-25, 2023. However, partial baths were not documented on the dates when a complete bath was not given. 3. In an interview, E1 and E2 reported R1 received partial baths every day a shower wasn't given, and E1 and E2 acknowledged the service provided was not documented in R1's medical record.

Based on observation, record review, and interview, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for one of two residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. The Compliance Officer observed the following medication bottle belonging to R2: -Metformin 500 mg tablets, take 1 tablet by mouth twice daily 2. A review of R2's medication administration record (MAR) dated June 2023 revealed R2 received medication administration of the above mentioned medication on June 1-27, 2023 at 8:00 AM. However, a medication order for Metformin 500 mg tablets was not available for review. 3. A review of R2's medical record revealed a list of medications R2 was prescribed: Metformin 500 mg tablets, take one tablet by mouth twice daily was included on the list. However, the list was not signed by a medical practitioner. 4. In an interview, E1 and E2 acknowledged R2 received medication administration without a medication order.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of Department documentation revealed the facility's license was effective on December 9, 2019. 2. A review of facility documentation revealed a policy titled "Disaster Drill/Evacuation and Safety Policy and Procedure." 3. A review of facility documentation revealed a form titled "Disaster Plan Review." However, the form was blank. 4. In an interview, E1 and E2 acknowledged the disaster plan was not reviewed at least once every 12 months.

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. Findings include: 1. A review of Department documentation revealed the facility's license was effective on December 9, 2019. 2. A review of facility documentation revealed an evacuation drill for employees and residents was completed on November 11, 2022, at 7:00 AM. However, additional documentation of evacuation drills for employees and residents conducted at least once every six months was not available for review. 3. In an interview, E1 and E2 acknowledged evacuation drills for employees and residents were not conducted at least once every six months. This is a repeat deficiency from the compliance inspections conducted on May 16, 2022.