Paradise Valley Senior Retreat

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident which included how an employee may submit a complaint related to resident care. The deficient practice posed a risk if an employee was unable to submit a complaint related to resident care. Findings include: 1. In documentation review, the facility's policies and procedures revealed no documentation covering how an employee may submit a complaint related to resident care. 2. In an interview, E1 reported not knowing a policy or procedure was required on how an employee may submit a complaint related to resident care. 3. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented, which covered the requirements in A.R.S. Title 36, Chapter 4, Article 11. The deficient practice posed a risk if an employee was unable to submit a complaint confidentially and without fear of retaliation. Findings include: 1. A.R.S. Title 36, Chapter 4, Article 11 states: "36-450.01.A. Each health care institution licensed pursuant to this chapter shall adopt a procedure for reviewing reports made in good faith by a health professional concerning an activity, policy or practice that the health professional reasonably believes both: 1. Violates professional standards of practice or is against the law. 2. Poses a substantial risk to the health, safety or welfare of a patient. B. The procedure shall include reasonable measures to maintain the confidentiality of the identity of a health professional providing information to a health care institution pursuant to this section." 2. A.R.S. Title 36, Chapter 4, Article 11 states: "36-450.02.A. Each health care institution that is licensed pursuant to this chapter shall adopt a policy that prohibits retaliatory action against a health professional who in good faith: 1. Makes a report to the health care institution pursuant to the requirements of section 36-450.01..." 3. In documentation review, the facility's policies and procedures revealed no documentation covering how an employee may submit a complaint related to resident care. 4. In an interview, E1 reported not knowing a policy or procedure was required on how an employee may submit a complaint related to resident care. 5. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. The deficient practice posed a risk if measures were not in place for staff to always know the whereabouts of a resident. Findings include: 1. In documentation review, the facility's policies and procedures revealed no documentation covering methods by which the facility was aware of the general or specific whereabouts of a resident, as required. 2. In an interview, E1 acknowledged not having a policy that covered methods by which the facility was aware of the general or specific whereabouts of a resident. 3. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk, as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. Review of the facility's policy and procedure manual revealed documentation indicating the policies and procedures were last reviewed by the manager on September 25, 2018. No additional documentation was available indicating the policies and procedures had been reviewed at least once every three years. 2. During an interview, E1 acknowledged documentation was not available indicating the facility's policies and procedures were reviewed every three years. 3. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on documentation review, record review, and interview, for one of five caregivers reviewed, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB), as required by R9-10-113. The deficient practice posed a potential health and safety risk of TB exposure to residents and staff. 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. In record review, E4's personnel record (hired as a caregiver on May 25, 2023), did not include documentation the caregiver provided evidence of freedom from infectious TB, including a screening and risk assessment, as required. 3. In documentation review, the staffing schedule for March 2024, included documentation the caregiver worked shifts at the facility. 4. During an interview, E1 acknowledged the personnel record for E4 did not include documentation E4 provided evidence of freedom from TB, as required by R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training before providing assisted living services, for one of four caregivers reviewed. The deficient practice posed a health and safety risk if the employee did not know how to properly perform first aid and/or CPR. Findings include: 1. Review of E4's personnel record revealed a hire date of May 25, 2023. 2. Review of E4's personnel record revealed a first aid and CPR card with an expiration date of July 2, 2024. 3. Review of the July 2024 personnel schedule revealed E4 worked from "7a-7p" on July 4, July 6, July 11, and July 13. 4. During an interview, E1 confirmed E4 worked multiple shifts after the expiration date of the first aid and CPR card. E1 acknowledged E4's personnel record did not include current documentation of first aid and CPR training.

Based on documentation review, 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. The deficient practice posed a direct health and safety risk for potential TB exposure to residents and staff. 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. In record review, R2's medical record did not include documentation of freedom from infectious TB. Based on the date of acceptance for R2, this documentation was required. 3. In documentation review, the facility's policies and procedures did not include a policy covering TB as specified in R9-10-113. 4. During an interview, E1 acknowledged R2's medical record did not include documentation of freedom from infectious TB. 5. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on record review and interview, the manager failed to ensure a residency agreement accurately included whether the manager or a caregiver was awake during nighttime hours, for two of two residents reviewed. The deficient practice posed a health and safety risk if a resident was unable to awaken the caregivers during nighttime hours. Findings include: 1. In record review, R1 and R2's residency agreement documented, "24-Hour Assistance and Supervision by certified Caregivers & Awake Staff at night." 2. In an interview, E1 reported caregivers sleep at night and wake up if the residents need assistance. E1 acknowledged R1 and R2's residency agreement did indicate staff were not awake at night.

Based on record review, and interview, for one of two residents reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated after a significant change in the resident's condition. 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, R2's medical record indicated R2 received Hospice services. The Hospice notes dated January 26, 2024 through July 15, 2024, indicated Hospice provided services for pain management, Foley care, wound care/dressing, disease process teaching, safety factors and dietary evaluation/fluid intake. 2. During an interview, E1 reported Hospice services were obtained for R2 because R2 was "mentally failing with Dementia, had chronic urinary tract infections, and developed wounds. 3. In record review, a review of R2's service plans indicated R2's service plan was last updated on January 2, 2024. The service plan did not include documentation of R2's change of condition; as indicated in paragraph #1 above, and the services to be provided for R2. 4. During an interview, E1 acknowledged R2's service plan was not updated, as required.

Based on record review, and interview, for one resident reviewed, who received directed care services, the manager failed to ensure a resident's written service plan was reviewed and updated at least once every three months. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. In record review, R1's medical record (received directed care and medication administration services) included a service plan dated August 5, 2022. The record did not include an updated service plan every three months, as required. 2. During an interview, E1 reported an updated service plan for R1 was not available for review, and acknowledged a service plan was required to be reviewed and updated at least once every three months, for a resident who received directed care services.

Based on observation and interview, the manager failed to ensure a calendar of planned activities was posted in a location that is easily seen by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed the facility did not have a planned activities calendar posted. 2. In an interview, E1 reported an activities calendar was located in the office; however, E1 acknowledged the facility did not have a planned activity calendar posted, as required. 3. Technical assistance was provided on this Rule during the compliance inspection conducted February 6, 2023.

Based on observation, record review, and interview, for two of two residents reviewed, the manager failed to ensure a caregiver documented the services provided in the resident's medical record. The deficient practice posed a risk if the services provided for residents were not documented, and the Department was unable to verify services were provided, as indicated. Findings include: 1. In observation, R1 and R2 were observed at the facility, and received assisted living services. R2 was observed to have a bandage on the left hand. 2. In record review, R1's service plan (SP) (received directed care and medication administration services), dated August 25, 2022, documented: "Medical History/Diagnosis; Low Sodium/Heart Issues/Blindness..." R1 required staff assistance with oral care, grooming/hygiene, nail care, bathing, and other activities of daily living, including incontinence care. 3. In record review, R1's medical record did not include documentation of the services provided for R1. 4. In record review, R2's SP (received personal care and medication administration services), was completed on January 11, 2022. The SP included documentation the SP was updated on January 7, 2023, July 7, 2023, and January 2, 2024. The service plan indicated, "Medical History/Diagnosis; Aging, CHF, Chronic Kidney disease." R2 required staff assistance with bathing; and required partial assistance with activities of daily living. 5. In record review, R2's medical record included Hospice notes dated January 26, 2024 through July 15, 2024, which indicated Hospice provided services for pain management, Foley care, wound care/dressing, disease process teaching, safety factors and dietary evaluation/fluid intake. 6. In record review, the Compliance Officer requested to review documentation of the services provided for R2, and was provided an "Activities of Daily Living," document for R2, dated January 2024. No further documentation, of the services provided for R2, was available for review. 7. During an interview, E1 reported R1 received directed care services, and R2 received personal care; however, R2's level of care changed recently to directed care services. E1 reported assisted living services were provided for R1 and R2; however were not documented by the caregivers, as required. 8. This is a repeat deficiency from the compliance inspection conducted on February 6, 2023.

Based on observation, record review and interview, for one of two residents reviewed, the manager failed to ensure the service plan, for a resident receiving directed care services, included skin maintenance to prevent and treat bruises, injuries, pressure sores, and infections. Findings include: 1. In observation, R2 was observed sleeping in a chair in the bedroom, and had a bandage on the left hand. 2. In record review, R2's medical record included Hospice notes dated January 26, 2024, through July 15, 2024, which documented R2 received wound care services and "dressing per physician order." 3. In record review, R2's medical record included a service plan (received "personal care services,") which documented (no date) "Patient back from Hospital... has blisters on the bottom of the left heel, made PCP aware and HH." The first page of the service plan indicated the original service plan was completed on "7/11/22" and "updated 1/7/23, 7/7/23, and 1/2/24." The service plan did not include skin maintenance services to prevent and treat R2's skin issues. 4. In record review, R2's medical record included medication orders for "Aquaphor ... topical ointment Reason: wound Aquaphor to wound per individual wound orders... chafing... apply to inner thighs and periarea as needed... Calmoseptine... topical ointment skin protectant apply thin layer to coccyx with each brief change... Gentamycin 0.1% topical Reason: wound apply topical to wounds to left buttocks daily, Nystatin ,.. topical ointment Reason: wound, apply topically to wound on left buttocks daily..." 5. During an interview, E1 reported R2's level of care recently changed from personal care to directed care services. E1 reported R2 had wounds, was prone to skin tears, and acknowledged R2's service plan did not include skin maintenance services. E1 reported the facility did not do anything for R2's wounds; the hospice agency treated the wounds.

Based on observation, record review, documentation review, and interview, for two of two residents reviewed, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record. The deficient practice posed a health and safety risk to a resident if a manager or caregiver did not document a medication was administered, and the Department was unable to verify a resident received medication, as ordered. Findings include: 1. In observation, the medications for R1 and R2 were observed on site, and available for administration. 2. In record review, R1's medical record included medication orders, dated March 28, 2024 for; Lisinopril 10 mg 1 tab QID po, Seroquel 25 mg 1 tab BID po, Senna S 8.6 mg 1 tab QD po, Metoprolol 25 mg 1 tab BID po, Venlafaxine ER 150 mg 1 tab QD po, and Trazadone 50 mg 1 tab QHS po. R1's medical record did not include documentation the medications were administered to R1. 3. In record review, R2's medical record included medication orders for Escitalopram 10 mg/day, Quetiapine 25 mg one tab po every morning and two tabs po every, Torsemide 20 mg 1 tab day po, Senna 8.6 mg two tabs every day or prn po, and orders for "Insulin Lispro (Humalog) U-100 Sliding Scale Sub Q with Meals Coverage: 70-150 = NONE 151 - 200 = 3 UNITS 201 - 250 = 6 UNlTS 251 - 300 = 9 UNITS 301 - 350 = 12 UNITS 351 - 400 = 14 UNITS >400 = 16 UNITS BEDTIME COVERAGE: 70 - 150 = NONE 151 - 200 = NONE 201 - 250 = 1 UNIT 251 - 300 = 2 UNITS 301 - 350 = 3 UNITS 351 - 400 = 4 UNITS >400 = 5 UNITS CHECKS TID... FINGER STICK BLOOD SUGAR CHECKS BEFORE MEALS AND AT BEDTIME." 4. In record review, R2's medical record did not include documentation the medications were administered to R2. The medical record included documentation of blood sugar checks, as required; however, did not include documentation the Insulin medication was administered, including the required units based on R2's blood sugar level. 5. In documentation review, a facility policy, titled, "H. Recording of medication assistance provided to residents & maintenance of medication records," on page 76, documented, "i. Medication administration is not documented until the resident is seen taking them. ii. Medications are administered to one resident at a time. iii. A separate medication record is maintained for each resident receiving .... or medication administration that includes: a. Name of resident b. Name of medication, dosage, directions, and route of administration; c. Date and time medication is scheduled to be administered; ... e. Signature or initials of the employee providing ... medication administration. iv. Monthly medication sheets will become a permanent record of resident's file...." 6. During an interview, the findings were reviewed with E1, who reported the facility administered the medications to R1 and R2, per the medication orders; however, reported the medication administration was not documented, as required.

Based on observation, documentation review, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closed, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During an environmental inspection of the facility with E2, the Compliance Officers observed an unlocked kitchen refrigerator. Medications were stored on the shelf of the refrigerator door that included Acetaminophen, Bisacodyl, an opened box of Gentle Laxative Suppositories, an opened box of Insulin Lispro Injection KwikPen and 2 insulin pens. The Compliance Officers observed an unlocked medication storage container stored on the same shelf that held 4 insulin pens. 2. A document review of a policy titled "Medications/Medication storage/Medication administration," on page 74, documented, "...storing and controlling of medication: i. Medication is stored in a locked container, cabinet, or area that is inaccessible to residents and ii. Medication is not left unattended by an employee..." 3. In an interview, E1 and E2 acknowledged medications were stored in an unlocked manner, and accessible to residents. 4. This is a repeat deficiency from the compliance inspection conducted on February 6, 2023.

Based on observation and interview, the manager failed to ensure the posted food menu included substitutions. Findings include: 1. During an environmental inspection, the Compliance Officers observed a food menu posted high on a wall by the front door. The menu was not dated, and indicated the lunch meal was Vegetable Beef Stir Fry with noodles, a garden salad, and garlic bread. 2. In observation, the lunch meal served to the residents included fried chicken nuggets, mashed potatoes and a vegetable. 3. During an interview, E1 acknowledged the posted food menu did not include the food substitutions no later than the morning of the day of meal service.

Based on observation and interview, the manager failed to ensure a refrigerator used by an assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3 \'b0F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential food borne illnesses. Findings include: 1. During the environmental inspection with E2, the Compliance Officers observed a thermometer in the refrigerator in the kitchen. However, the thermometer was broken and not accurately measuring the temperature. The thermometer reading was 0 degrees. 2. In an interview, E2 acknowledged the kitchen refrigerator did not contain a working thermometer accurate to plus or minus 3 \'b0F.