Norterra Assisted Living LLC

Based on Department documentation, record review, and interview, for one of three employees reviewed, the manager failed to ensure a caregiver had a valid caregiver training certificate. The deficient practice posed a health and safety risk to residents if a caregiver did not complete the required training program, and the Department was provided false and misleading information. Findings include: 1. A review of Department records revealed the facility had a prior compliance inspection conducted on May 16, 2022. The Statement of Deficiency report included a deficiency cited because E2 was found working at the facility as an assistant caregiver alone with residents, without having a caregiver certificate. The report documented "E1 stated E2 "was hired as an assistant caregiver." E1 reported E2 was still working as an assistant caregiver and did not have a caregiver certificate." 2. A review of Department records revealed the facility submitted a plan of correction for the deficiency which documented, "5/17 staffing schedules re configured to ensure a CG and/or manager is present with assistant CG at all times. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur..." The Department received no documentation from the facility to dispute the deficiency. 3. During the compliance inspection conducted on September 11, 2023, E3 (the same person identified as E2 during the May 16, 2022 inspection) was observed working at the facility. 4. In record review, E3's personnel record included documentation E3 was hired as caregiver on June 1, 2022. The personnel record did not include documentation of prior employment at the [Facility]. The record included a caregiver certificate for E3, dated January 28, 2004. E3's fingerprint clearance card was issued March 14, 2022. 5. During an interview, the findings were reviewed with E1, who reported E3 had a caregiver certificate in the record during the prior inspection but the compliance officer didn't see it. E3 also reported the prior manager didn't know. E1 acknowledged the findings.

Based on observation, record review, and interview, for one of two caregivers reviewed, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services or behavioral health services. The deficient practice posed a health and safety risk to residents, if a caregiver did not have the documented skills and knowledge to provide care and services for a resident. Findings include: 1. In observation, E3 was observed working at the facility as a caregiver. 2. In record review, the personnel record for E3 (hired June 1, 2022, as a caregiver), did not include documentation the caregiver's skills and knowledge, were verified and documented. 3. During an interview, E1 acknowledged the verification of skills and knowledge for E3, was not documented, as required.

Based on record review and interview, for one of three employees reviewed, the manager failed to ensure a personnel record included documentation of evidence of freedom from infectious tuberculosis (TB), which posed a potential health and safety risk of TB exposure, to residents and staff. Findings include: 1. In record review, E3's personnel record (hired as a caregiver on June 1, 2022), did not include documentation of freedom from TB, as required. 2. During an interview, E1 reported having documentation of E3's TB test; however, reported being unable to locate the documentation.

Based on record review, observation, and interview, for two of two caregivers reviewed, the manager failed to ensure a caregiver provided documentation of cardiopulmonary resuscitation training (CPR) certification specific to adults, which included a demonstration. The deficient practice posed a health and safety risk to residents if caregivers did not have CPR training which included a demonstration of the employee's ability to perform CPR. Findings include: 1. In record review, the personnel records for E1 (hired May 1, 2020, as a caregiver) and E3 (hired June 1, 2022, as a caregiver) included documentation of completion of CPR certification provided by NationalCPRFoundation which is an online training program, and did not include a demonstration of an individual's ability to perform CPR. 2. In observation, E1 and E3 were the only caregivers observed working at the facility during the inspection. 3. During an interview, the findings were reviewed with E1, who acknowledged the CPR training for the employees was received online, did not include the required demonstration of the employee's ability to perform CPR.

Based on observation, record review, and interview, for two of four employees reviewed, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation. The deficient practice posed a safety risk to residents if the Department was unable to verify new employees were provided orientation in accordance with the facility's policies and procedures. Findings include: 1. In observation, E3 was observed working at the facility during the inspection. 2. In record review, E3's personnel record indicated E3 was hired on June 1, 2022, and did not include documentation of orientation. 3. In record review, E2's personnel record (hired as a manager on May 1, 2023) did not include documentation of orientation. 4. During an interview, E1 reported the personnel records for E2 and E3 did not include documentation of orientation.

Based on record review and interview, for two of two residents reviewed, the manager failed to ensure a resident's written service plan included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. In record review, R1's medical record (received personal care services) included documentation of diagnoses as "heart failure, Parkinson's disease, Hypertension, Bipolar, Asthma, PVD, GERD, and history of pressure ulcer to coccyx." R1's service plan did not include documentation of R1's medical and health problems. 2. In record review, R2's medical record (received directed care services) included documentation R2 had Dysphagia, Agitation, Hypertension and Glaucoma." R2's service plan did not include documentation of R2's medical and health problems. 3. During an interview, the findings were reviewed with E1, who acknowledged the residents' service plans did not include a description of the resident's medical and health problems, as required.

Based on observation, record review, and interview, for one resident who stored medication in their bedroom, the manager failed to ensure the service plan included how the medication was stored and controlled. The deficient practice posed a health and safety risk if medication was not stored in a safe and secure manner. Findings include: 1. During an environmental inspection with E1, R1 was observed in bed with medications stored on R1's bedside table. The medications were Nystatin cream, Neomycin ointment, Fluticasone, and Artificial Tears. 2. In record review, R1's service plan, dated July 1, 2023, documented, "Staff controls, secures and administers medications..." The service plan did not include documentation of how the medications were stored and controlled in R1's bedroom. 3. During an interview, E1 acknowledged medication was stored in R1's bedroom, and the resident's service plan did not include documentation of how the medication was stored and controlled.

Based on record review, and interview, for two of two residents reviewed, the manager failed to ensure a resident's medical record contained a copy of the health care power of attorney (POA) or guardianship. The deficient practice posed a risk if the facility did not obtain and adhere to a resident's documentation of representation. Findings include: 1. In record review, R1's medical record indicated R1 had a POA, who signed R1's acceptance documentation. R2's medical record indicated R2 had a POA, who signed R2's acceptance documentation. The medical records for R1 and R2 did not include a copy of the residents' POA documents. Based on the residents' acceptance dates, this documentation was required to be in the residents' records. 2. During an interview, E1 acknowledged the medical records for R1 and R2 did not include a copy of the residents' POA documentation.

Based on record review and interview, for two of two resident's medical records reviewed, and receiving medication administration services, the manager failed to ensure a resident's medical record included the time of medication administration. The deficient practice posed a health and safety risk to residents if medications were not documented as administered timely per the medication orders. Findings include: 1. In record review, R1's medical record (received personal care and medication administration services) included medication orders for Tramadol 50mg, 1 tab po TID, Olanzapine 5mg, 1 tab po BID, Methenamine 1 G, 1 tab BID, Carbidopa Levadopa 50-200, 1 tab po QD, Potassium 20meq, 1 tab before breakfast , Toterodine 4mg, 1 cap po QD, Levocetirizine 5mg, 1 tab po QD prn, Montelukast 10mg, tab QD, prn, Ropinirole HCL, 1 mg, t tab po TID, Nystatin 10K topical 2 x day, and Benadryl 25mg 1 tab po BID. 2. In record review, R1's medication administration record (MAR) included documentation R1 received the medications daily, as ordered, from August 1, through September 10, 2023. The MAR did not include the time the medications were administered, and documented only "am," "pm" or "HS." 3. In record review, R2's medical record (received directed care and medication administration services) included medication orders for Tylenol 500mg, 2 tabs TID, Citalopram 20mg, po QD, Miconazorb 2% powder topical BID prn, Amlodipine 5mg, 1 tab po at pm, Hydralazine 25mg, 1 tab QD, Lumigan 0.01%, 1 drop both eyes q HS, Senna Lax 8.6mg, 2 tab po BID and Trazadone 50mg, po QHS. 4. In record review, R2's MAR, dated September, 2023, included documentation R2 received the medications daily, as ordered; however, the MAR did not include the time the medications were administered, and documented only "am," "pm" or "HS." 5. During an interview, E1 acknowledged the time of the medication administration had not been documented on the resident's medication administration records.

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident's medical record contained documentation of notification of the residents of the availability of vaccination for influenza and pneumonia vaccination. The deficient practice posed a health and safety risk if a resident or representative did not have knowledge of the availability of the vaccination. The statue reads: A.R.S. \'a7 36-406(1)(d) 36-406. Powers and duties of the department In addition to its other powers and duties: 1. 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. Findings include: 1. In record review, R2's medical record (received directed care services) did not include documentation of notification of the resident's representative of the availability of vaccination for influenza and pneumonia. Based on the resident's acceptance date, this documentation was required. 2. During an interview, the findings were reviewed with E1, who acknowledged R2's record did not include documentation the vaccinations were made available to the resident.

Based on observation, record review, and interview, for two of two residents reviewed, who were unable to walk and receiving directed care services, the manager failed to ensure the resident's primary care provider (PCP) or other medical practitioner (MP) examined the resident at the onset of the condition and at least every six months throughout the duration of the resident's condition, reviewed the facility's scope of services, and signed and dated a determination stating the resident's needs were being met by the facility. The deficient practice posed a health risk to a resident if a resident's condition was not reviewed by a PCP or MP, to approve a resident's stay at the facility. Findings include: 1. In observation, the surveyor observed R1 and R2 at the facility during the inspection. Both residents were observed in bed. 2. In record review, the medical records for R1 and R2 did not include a signed and dated determination stating the residents' needs could be met by the facility. 3. During an interview, E1 reported R1 and R2 were unable to walk, even with assistance, and were unable to walk when accepted at the facility. E1 acknowledged the records for R1 and R2 did not include a signed and dated determination stating the residents' needs could be met by the facility.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures for administering an opioid that covered how, when, and by whom a patient's need for opioid administration is assessed; how, when, and by whom a patient receiving an opioid is monitored; and how, when, and by whom the actions taken according to subsections (F)(1)(c) and (d) are documented. The deficient practice posed a safety risk to residents if the opioid rules were not understood and implemented by staff administering medications. Findings include: 1. In documentation review, the facility had two sets of policies. The policies in current use did not include policies and procedures covering opioid medication. However, the facility's second set of policies (reported by E1, not yet adopted by the facility) included a policy and procedures covering opioid medication administration; however, did not include all required documentation per R9-10-120.F. The policies did not include how and when a patient's need for opioid administration is assessed, and how and when a patient receiving an opioid is monitored, and how, and when the the actions taken are documented. 2. In record review, R1's medical record (received personal care and medication administration services) documented R1 received opioid medication administration daily in August and September, 2023. 3. During an interview, E1 reported being unaware of the opioid medication administration rules, and acknowledged the facility had not established, documented, and implemented policies and procedures for administering an opioid as part of treatment, to protect the health and safety of a patient.

Based on observation, record review, and interview, for one resident reviewed, and receiving opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual, authorized to administer opioids, documented in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident if the resident's level of pain was not documented, as required. Findings include: 1. In observation, R1 had Tramadol medication (a schedule IV controlled substance and opioid), on site and stored by the facility. The medication package indicated 30 pills were dispensed on August 3, 2023, with 7 pills remaining. 2. In record review, R1's medical record included a medication order for Tramadol 50mg, take 1 tab TID by mouth. R1's Medication Administration Record (MAR) for August 1-31, and September 1- 10, 2023, included documentation R1 received the opioid medication three times daily, as ordered. However, the record did not include documentation of an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. R1's medical record did not include documentation of an active malignancy or end of life condition. 3. During an interview, E1 reported R1 received the Tramadol for pain, and did not have an end of life condition or an active malignancy. E1 acknowledged the facility did not document in the resident's medical record an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered.