Olive Park Assisted Living

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the facility quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Quality Management Program" reviewed and signed by E3 February 25, 2023. This policy stated "...4. The manager submits a documented report to the governing authority on a quarterly basis..." 2. Review of the quality management program documentation revealed the last quality management report was completed May 2023. 3. In an interview, E1 acknowledged the quality management report was not submitted per the frequency established in the quality management program.

Based on record review and interview, the manager failed to ensure a resident provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of one resident reviewed. 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. 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 acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R1 did not provide documentation of freedom from infectious TB as specified in R9-10-113. 4. Technical assistance was provided on this Rule during the compliance inspection conducted November 9, 2022.

Based on documentation review, record review, and interview, the manager failed to ensure the policy and procedure and a residency agreement contained provisions allowing a manager to terminate residency of a resident in compliance with A.A.C. R9-10-807(G), for one of one resident reviewed accepted by the assisted living facility on or after October 1, 2019. The deficient practice posed a health and safety risk to the residents. Findings include: 1. Rule review of R9-10-807(G) on or after October 1, 2019 stated: "A manager 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." Review of subsection (C) stated: "1. The individual requires continuous: a. Medical services; b. Nursing services unless the assisted living facility complies with A.R.S.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 assisted living 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." 2. Review of the facility's policy and procedure revealed a policy titled "Resident Acceptance, Rights, and Termination" reviewed and signed by E3 February 25, 2023. The policy and procedure did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -The assisted living 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. 3. Review of R1's medical record revealed a residency agreement. This residency agreement did not include the correct provisions allowing a manager to terminate residency of a resident. The residency agreement did not include the following terms for a 14 day termination: -The primary condition for which the individual needs assisted living services is a behavioral health issue; and -The assisted living 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. Based on R1's acceptance date, this documentation w

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 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. Review of R2's medical record revealed R2 refused the pneumonia vaccination June 1, 2022. However, current documentation was not available that showed the pneumonia vaccination was offered or received. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R2's medical record did not include current documentation that showed the pneumonia vaccination was offered or received.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan. Findings include: 1. Review of the December 2023 personnel schedule revealed two shifts; 7am -7pm (day shift) and 7pm - 7am (night shift). 2. Review of the facility's employee disaster drills revealed the most current disaster drill conducted June 17, 2023 on the day shift and night shift. No other employee disaster drills were available after June 17, 2023. 3. In an interview, E1 acknowledged the employee disaster drills were not conducted on each shift at least once every three 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 the evacuation plan. Findings include: 1. Review of the facility's employee and resident evacuation drills revealed the most current drill conducted March 18, 2023. No other employee and resident evacuation drills were available after March 18, 2023. 2. In an interview, E1 acknowledged the employee and resident evacuation drills were not conducted at least once every six months.

Based on observation and interview, the manager failed to ensure an evacuation path was conspicuously posted on each hallway of each floor of the assisted living facility. The deficient practice posed a risk as a way to exit the facility in the event of an emergency was not posted. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed the interior hallway and the hallway on the north side of the facility did not have a posted evacuation path. 2. In an interview, E1 acknowledged the evacuation path was not posted on each hallway of the assisted living facility. 3. Technical assistance was provided on this Rule during the compliance inspection conducted November 9, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure a smoke detector was tested at least once a month. The deficient practice posed a health and safety risk if the smoke detectors did not work properly during an emergency. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed that there was no fire alarm system. 2. Review of the facility's smoke detector testing documentation revealed the last smoke detector testing was completed August 2023. 3. In an interview, E1 reported the smoke detectors had not been tested monthly.

Based on observation and interview, the manager failed to ensure 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 a resident. Findings include: 1. During an environmental inspection of the facility with E1, the Compliance Officer observed LA's Totally Awesome Bleach, Great Value Automatic Dishwasher Pacs, and Furniture Polish unlocked in the cabinet under the kitchen sink. This cabinet had a locking device, however the device was not locked. 2. During an observation, the caregiver was not accessing the toxic materials at the time of arrival. 3. In an interview, E1 acknowledged toxic materials were stored unlocked. 4. Technical assistance was provided on this Rule during the compliance inspection conducted November 9, 2022.

Based on observation, interview, and documentation review, the licensee failed to submit a request for approval of a modification of a health care institution. Findings include: 1. During an environmental tour of the facility with E1, the Compliance Officer observed a modification to the facility. The garage was converted into two new bedrooms. These rooms were being used for storage. 2. In an interview, E1 reported the modification was finished approximately two years ago, however did not have a City permit. 3. Review of Department records revealed no documentation of a request for approval for the modification. 4. In an interview, E1 acknowledged a request for approval for the modification was not submitted to the Department.

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included an annual assessment of the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility documentation revealed no policy and procedure that included an annual assessment of the health care institution's risk of exposure to infectious TB. 2. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted November 9, 2022.