Ohana Adult Care Home LLC

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's day of occupancy, for two of four residents reviewed. The deficient practice posed a TB exposure risk to residents. Findings include: 1. A review of R2's (admitted in 2023) medical record revealed evidence of freedom from infectious TB. However, the test was completed 29 calendar days after R2's date of admission. 2. A review of R2's medical record revealed documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB was not available for review. Based on R2's acceptance date, this documentation was required. 3. A review of R4's (admitted in 2023) medical record revealed evidence of freedom from infectious TB. However, the test was completed 27 calendar days after R4's date of admission. 4. In an interview, E1 and O1 acknowledged R2 did not provide documentation of a risk assessment of prior exposure to infectious TB or a determination if R2 had signs or symptoms of TB. 5. In an interview, E1 and O1 acknowledged R2's and R4's evidence of freedom from infectious TB was not completed before or within seven calendar days after the resident's date of occupancy.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for four of four 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, R2's, R3's, and R4's medical records revealed current service plans describing the services to be provided by the facility personnel members to each resident. 2. A review of R1's, R2's, R3's, and R4's medical records revealed an activities of daily living (ADL) log for September 2023. R1's, R2's, R3's, and R4's ADL logs did not indicate services were provided on September 22 - 25, 2023. 3. In an interview, E1 and O1 acknowledged R1's, R2's, R3's and R4's medical records did not include documentation of services provided and reported the services were provided, however a caregiver or an assistant caregiver did not document the services provided.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of four residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R2's medical record revealed a medication order dated September 22, 2023. The medication order revealed Levothyroxine 175 mg, one tab, daily was discontinued. 2. A review of R2's medical record revealed a medication administration record (MAR) dated September 2023. The MAR revealed Levothyroxine 175 mg, one tab daily was given on September 24, 2023. 3. The Compliance Officer observed a medication bottle, belonging to R2, labeled for Levothyroxine 175 mg. 4. In an interview, E1 reported the medication was administered per the MAR and acknowledged R2's medication was administered although there was a medication order to discontinue the medication.

Based on documentation review, record review, observation, and interview, the manager failed to implement policies and procedures for discarding medication. The deficient practice posed a risk as the standards expected of employees in the policies and procedures were not followed. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Disposal of Expired Medication" (dated in August 2022). The policy and procedure stated "Medication must be disposed of when it is... discontinued by the resident's physician.... 1. Take unused, unneeded or expired prescription drugs out of their original containers. 2. Mix the prescription drugs with a undesirable substance like coffee grounds or kitty litter, and put them in impermeable, nondescript containers... 3. Throw these containers in the trash..." 2. A review of R2's medical record revealed a medication order dated September 22, 2023. The medication order revealed Losartan 50 mg, one tab, at bedtime and Levothyroxine 175 mg, one tab, daily were discontinued. 3. The Compliance Officer observed medication bottles, belonging to R2, labeled for Losartan 50 mg and for Levothyroxine 175 mg. 4. In an interview, E1 and O1 acknowledged the medications were not disposed of according to the facility's policy and procedure.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 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 R3's medical record revealed documentation of an investigation of the alleged abuse regarding E3 was not available for review 3. A review of R2's medical record revealed an activities of daily living (ADL) log for April 2023 and May 2023. However, the ADL log revealed complete baths were only provided on the following dates: -April 23, 2023; and -April 28, 2023. 4. The Compliance Officer requested to review R5's medical record. However, R5's medical record was not provided for review. 5. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager, who had a reasonable basis to believe abuse had occurred, failed to comply with the requirements. The deficient practice posed a risk to a resident's health and safety, 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.R.S. \'a7 46-454. states, "Duty to report abuse, neglect and exploitation of vulnerable adults; duty to make medical records available; violation; classification A. A health professional...or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...All of the above reports shall be made immediately by telephone or online. B. If an individual listed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law, the individual is deemed to have complied with the requirements of subsection A of this section by reporting or causing a report to be made to the health care institution in accordance with the health care institution's procedures." 2. A review of R3's medical record revealed progress notes. The progress notes stated the following: "3/1/2023... [E1] witnessed that [R3] said 'I am going to marry "Larry" ([R3] calls [E3] "Larry")... 3/2/2023 [R3] asked me 'where is my husband Larry?' [E1] told [R3] 'you're not married to [E3], [E3] is my employee' ... [R3] said 'why can't I marry [E3] and have sex with [E3]'... 3/10/2023... [R3] told [E1], 'I want to give [E3] sexual favor. [E3] wouldn't let me.' [E1] told [R3] 'no, stop that, it's inappropriate.' [R3] said 'well then I might just kill myself'... 3/15/2023... [R3] told hospice nurse that [E3] is [R3's] husband. House rule that [R3] can't have sex with [E3]. Both nurse and I told [R3] that is inappropriate to talk like that [E3] is not [R3's] husband. [R3] yelled at us and said 'why you telling me a lie. [E3's] my husband. We got engaged. [E3] proposed to me'... 3/28/2023... [R3] all day talking about how [E3] was [sic] sex with [R3] then '[E3] raped me. [E3] should be in jail, call the cops.' Then at dinner table [R3] was accusing and yelling and screaming at new resident... 'why is [E3] still here. [E3] raped me. [E3] should be in jail. I scratch [E3] eyeballs out." 3. A review of R3's medical record revealed documentation of an investigation of the alleged abuse regarding E3 was not available for review. 4. In an interview, E1 reported calling Adult Protective Services but was unable to provide documentatio

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of five residents sampled. The deficient practice posed a risk if a resident did not receive their required services, 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 for directed care services dated in April 2023. The service plan stated "Bath:... assist by caregiver... Times per Week:... 2... Partial Bath... on days when complete bath not given..." 2. A review of R2's medical record revealed an activities of daily living (ADL) log for April 2023 and May 2023. The ADL log revealed complete baths were provided on the following dates: -April 23, 2023; and -April 28, 2023. 3. In an interview, E1 reported R2 was going to move out a couple of days after being admitted and had forgotten to give R2 a complete bath. E1 acknowledged R2 was not provided the assisted living services in the resident's service plan.

Based on observation, record review, and interview, the manager failed to ensure a resident was not subjected to restraints. The deficient practice posed a potential for psychological distress and physical injury. Findings include: R9-10-807(C)(5) A manager shall not accept or retain an individual if the individual requires restraints, including the use of bedrails. 1. The Compliance Officer observed R1's bed to have bed rails on both sides of the bed. 2. A review of R1's medical record revealed a service plan for personal care services dated January 2023. The service plan revealed R1 was non-ambulatory and required one person assists. Additionally R1 was a high fall risk. 3. A review of R1's medical record revealed a document titled "Determination Form" dated in January 2023. The document revealed R1 did not require restraints. 4. A review of R1's medical record revealed progress notes. The progress notes stated, "February 9, 2023... 2:30 AM. [E1] heard scream. [E1] went to check on [R1]. [R1] completely took off [R1's] collar from [R1's] neck. Rail pad on the floor. [R1's] lower leg over the rail. Placed collar, put back rail pad. Once again all night long moaning very loudly and restless movement... February 10, 2023...[R1] yelling 'help'. Trying to get out of bed 4x - at 10:30 pm [R1] yelling from [R1's] sleep 'help'. [E1] went to check on [R1]. [R1] wanted to get out... February 21, 2023... [E1] yell 'help'. [E1] went to room. [R1] had removed [R1's] neck brace, all the clothing including diaper, hanging out of bed (over the rail) ready to get out..." 5. In an interview, E1 reported putting the bed rails on the keep R1 in bed at night. E1 reported R1 is not able to remove the bed rails without assistance. 6. In an interview, E1 reported receiving a note from the doctor stating R1 required bed rails. E1 reported being unaware that was not acceptable.

Based on observation and interview, the manager failed to ensure a medical record is maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for one of two discharged 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: A.R.S. \'a7 12-2297(A)(1) Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider. 1. The Compliance Officer requested to review R5's medical record. However, R5's medical record was not provided for review. 2. In an interview, E1 reported R5 only stayed at the facility for three weeks. E1 reported R5 took R5's record from the facility. 3. In an interview, E2 acknowledged R5's medical record was not maintained.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed an accessibility risk to residents. Findings include: 1. The Compliance Officer arrived at the facility at approximately 9:30 AM. 2. The Compliance Officer observed two ambulatory residents on premises. 3. The Compliance Officer observed an unlocked medication cabinet in the dining area. The cabinet contained a locking device, however, the locking device was not engaged and the key was stored on top of the cabinet. 4. The Compliance Officer observed E2 and E3 were the only employees at the facility when the Compliance Officer arrived and were not accessing the medications at the time of the Compliance Officer's arrival. 5. In an interview, E1 acknowledged medications were stored unlocked.

Based on observation, documentation review, record review, and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to the posted menu. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. The Compliance Officer arrived at the facility at approximately 9:30 AM. 2. The Compliance Officer observed a posted menu on the refrigerator. However, the menu did not include the dates for May 1, 2023 through May 6, 2023. 3. In an interview, E4 reported E4 forgot to print the menu for the first week of May. However, E4 provided the current menu to the Compliance Officer at the time of the inspection. 4. A review of the menu, provided by E4, revealed "Breakfast: Ham & Cheese Biscuit, Milk/Coffee/Juice, Snacks: Muffins/Cookies, Lunch: Baked Chicken, Mashed Potatoe, Dessert: Ice Cream, Drinks: Soda/Juice/H2O..." 5. In an interview, R1 and R2 reported having one egg, some toast, banana slices, and water for breakfast. 6. The Compliance Officer observed E2 serving lunch. The lunch E2 serviced was a meat and cheese sandwich, vegetable chips, chocolate pudding, and water. 7. In an interview, E1 stated "I haven't been paid but I still feed them well." E1 acknowledged the breakfast and lunch served were not per the menu provided.

Based on record review and interview, the manager failed to ensure when a resident had an emergency resulting in the resident needing medical services, a caregiver documented the date and time of the incident, a description of the accident, emergency, or injury, the names of individuals who observed the incident, the individuals notified by the caregiver, and any action taken to prevent the incident from occurring in the future. 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/ at the exit ??? Findings include: 1. A review of R1's medical record revealed a progress note. The progress note stated, "April 28, 2023... 3pm, call 911 for [R1]. Fever 102." 2. The Compliance Officer requested to review the documentation of the incident involving R1 on April 28, 2023. However, documentation was not provided for review. 3. In an interview, E1 acknowledged the required information was not documented for R1's incident.