Our Grouphome LLC

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for three of the three personnel sampled. The deficient practice posed a risk if E1, E2, and E3 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(4) states, “On or before March 31,2025, verify that each employee is not on the adult protective services registry (APS) pursuant to section 46-459…” 2. While on-site for the compliance inspection, the Compliance Officers observed E2 and E3 at the facility, providing services to residents. 3. A review of E1's, E2’s, and E3's personnel records revealed no documentation check of the adult protective services registry. 4. A review of the adult protective services registry revealed that E1, E2, and E3 were not on the registry. 5. In an interview, E2 acknowledged that the facility did not verify that E1, E2, and E3 were not on the adult protective services registry.

Based on 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. Findings include: 1. A review of E2 and E3's personnel record revealed no documentation of fall recovery training. Review of E4's personnel record revealed no documentation of fall prevention and fall recovery training. 2. In an interview, E1 reviewed E2, E3, and E4's personnel records and acknowledged the records revealed no documentation of the identified fall prevention and fall recovery training. This is a repeat deficiency from the compliance inspection conducted July 15, 2022.

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which requires immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager. Findings include: 1. Review of Department records indicated O1 as the facility manager. The Department records revealed on July 7, 2023, written notification was received by the Department identifying E4 as the current facility manager. 2. At the time of the survey, the surveyor observed a notification posted on the wall near the front door indicating E4 was the manager. 3. Review of E4's record revealed E4's starting date was June 1, 2023 as the manager. 4. During a telephone interview, O1 acknowledged E4 was the facility's certified manager. O1 reported O1 notified the nursing board and O1 had believed to have notified the Department however no documentation was provided for review. 5. In an interview, E1 reported E4 was the current certified manager as of June 1, 2023. E1 acknowledged E1 did not have documentation to demonstrate the governing authority immediately notified the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager.

Based on documentation review, record review, and interview, the manager failed to ensure a policy and procedure was developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident's health and safety. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. A request for the facility's policy and procedure for checking on a resident receiving directed care services during nighttime hours revealed a policy provided by E1 titled "Safety of wandering residents" signed by O1 December 12, 2022. The policy stated caregivers on duty will verify the present of confused residents in the facility at least every two hours." The policy did not reveal any additional procedure for checking on a resident receiving directed care services during nighttime hours to ensure the residents' health and safety. 3. A review of R1 and R2's medical record revealed R1 and R2 received directed care services. R1 and R2's medical record revealed a monthly activities of daily living log with a section titled "night checks 10 pm, midnight, 2 am, and 5 am." R1 and R2's medical record revealed no documentation of night checks documented for R1 and R2 for the months of February 2023, March 2023, April 2023, May 2023, June 2023, and July 2023. 4. In an interview, E2 reported the staff sleep at night and wake every few hours to check on the residents. E2 reported E2 completed night checks on the residents every few hours. E2 acknowledged E2 did not document the night checks in R1 and R2's medical record. 5. In an interview, E1 reported the staff members sleep at night and wake periodically to check on the residents. E1 reviewed R1 and R2's medical records. E1 acknowledged no additional documentation was available for review to demonstrate documentation for checking on a resident receiving directed care services during nighttime hours to ensure the resident's health and safety.

Based on record review and interview, the manager failed to ensure a written service plan was completed no later than 14 calendar days after the resident's date of acceptance for one of two residents reviewed. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. Review of R2's record revealed written service plans which were dated more than 14 calendar days after R2's acceptance to the facility. R2's medical record revealed no other service plan was available for review. Based on R2's acceptance date, R2's medical record revealed no service plan was completed within 14 calendar days after R2's acceptance to the facility. 2. During an interview, E1 reviewed R2's medical record. E1 acknowledged no additional service plans were available for review. E1 acknowledged R2's service plan was not completed within 14 calendar days of acceptance.

Based on record review and interview, the manager failed to ensure a service plan included documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting, cognitive stimulation and activities to maximize functioning, and strategies to ensure a resident's personal safety for two of two residents reviewed receiving directed care services. The deficient practice posed a health risk to the resident. Findings include: 1. Review of R1's record revealed a current written service plan for directed care services dated June 26, 2023. This service plan revealed no documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting, skin maintenance to prevent and treat bruises, injuries, pressure sores, activities to maximize functioning; and strategies to ensure personal safety. 2. Review of R2's record revealed a current written service plan for directed care services dated June 15, 2023. This service plan revealed no documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting, skin maintenance to prevent and treat bruises, injuries, pressure sores, activities to maximize functioning; and strategies to ensure personal safety. 3. In an interview, E1 reviewed R1 and R2's service plans. E1 acknowledged the identified service plans failed to include documentation of incontinence care that ensured the resident maintained the highest practicable level of independence when toileting, skin maintenance to prevent and treat bruises, injuries, and pressure sores, activities to maximize functioning, and strategies to ensure personal safety.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated for two of two residents reviewed receiving directed care services. Findings include: 1. Review of R1's record revealed a current written service plan for directed care services dated June 26, 2023. This service plan revealed no documentation of R1's weight. A review of R1's record revealed no documentation from a medical practitioner stating weighing R1 was contraindicated. 2. Review of R2's record revealed a current written service plan for directed care services dated June 16, 2023. This service plan revealed no documentation of R2's weight. A review of R2's record revealed no documentation from a medical practitioner stating weighing R2 was contraindicated. 3. In an interview, E1 reviewed the identified medical records. E1 acknowledged the service plans did not include documentation of the residents' weight. E1 acknowledged additional documentation was not available from a medical practitioner stating weighing the identified residents was contraindicated.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver immediately notified the resident's primary care provider. Findings include: 1. Review of R3's medical record revealed a document titled "Incident Report" dated January 4, 2023. This document indicated "...Caregiver called manager and reported that patient passed out in the bathroom...called 911." R3 was transported to Banner Estrella Hospital. This document revealed no documentation R3's primary care provider was notified. 2. During an interview, E1 reviewed R3's incident report. E1 acknowledged R3's medical record revealed no documention showing R3's primary care provider was immediately notified when R3 had an incident resulting in needing medical services.

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. Findings include: 1. During the facility tour with E1 and E2, the compliance officer observed two containers of Disinfectant Wipes stored on a lower level shelf near the facility entrance. 2. In an interview, E1 and E2 acknowledged the toxic materials were stored by the facility unlocked and accessible to residents. E1 acknowledged the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted July 15, 2022.