Pronghorn Assisted Living LLC

Based on observation, documentation review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover staffing. Findings include: 1. The Compliance Officers observed E1, E4, and E5 working on the premises. 2. A review of facility documentation revealed a policy and procedure titled "Staffing and Record Keeping" (dated March 10, 2023). The policy and procedure stated "6. The facility governing authority will assist the facility manager to hire an additional on call caregiver available to cover shifts if the manager or caregiver assigned to work is not available or not able to provide the required assisted living services to the residents. This caregiver must qualify to be the manager designee. ... 7. If applicable, the facility licensee or governing authority shall act as a back-up caregiver. The facility manager might provide assisted living services when there is a shortage of staff. ... 10. A work schedule is developed with all volunteers and staff members who provide assisted living services to residents and is maintained at the facility for at least 12 months from the date of the work schedule. ... 11. Back-up personnel must be documented in the work schedule to ensure that there is a manager or caregiver available as back-up to provide assisted living services to a resident if the manager or caregiver assigned to work is not available or not able to provide the required assisted living services." 3. In an interview, E1 reported two personnel members would be the back-up caregivers. E1 reported the personnel members live in Phoenix and not in Prescott Valley. E1 reported a registered nurse who lives in Prescott Valley would come to AL11324 as a back-up to provide assisted living services. 4. A review of facility documentation revealed staffing schedules for August 2023 and September 2023. However, the staffing schedules for August 2023 and September 2023 did not document the two personnel members who live in Phoenix and the registered nurse who lives in Prescott Valley as back-up personnel. 5. A review of facility documentation revealed staffing schedules for August 2023 and September 2023. However, the staffing schedules for August 2023 and September 2023 did not document the hours worked for E4 and E5. 6. In an interview, E1 acknowledged policies and procedures were not implemented to protect the health and safety of a resident to cover staffing.

Based on observation, documentation review, record review, and interview, the manager failed to ensure documentation was maintained of the assistant caregivers working each day, including the hours worked. Findings include: 1. The surveyor observed E1, E4, and E5 on the premises and working. 2. A review of facility documentation revealed a policy and procedure titled "Staffing and Record Keeping" (dated March 10, 2023). The policy and procedure stated "10. A work schedule is developed with all volunteers and staff members who provide assisted living services to residents and is maintained at the facility for at least 12 months from the date of the work schedule." 3. A review of facility documentation revealed staffing schedules for August 2023 and September 2023. However, the staffing schedules for August 2023 and September 2023 did not document the hours worked for E4 and E5. 4. A review of E4's (hired in February 2023) and E5's (hired in February 2023) personnel records revealed E4 and E5 were hired as assistant caregivers. 5. In an interview, E1 acknowledged documentation was not maintained to include the hours worked each day by E4 and E5.

Based on documentation review, and interview, the manager failed to implement a plan to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Staffing and Record Keeping" (dated March 10, 2023). The policy and procedure stated "6. The facility governing authority will assist the facility manager to hire an additional on call caregiver available to cover shifts if the manager or caregiver assigned to work is not available or not able to provide the required assisted living services to the residents. This caregiver must qualify to be the manager designee. ... 7. If applicable, the facility licensee or governing authority shall act as a back-up caregiver. The facility manager might provide assisted living services when there is a shortage of staff. ... 11. Back-up personnel must be documented in the work schedule to ensure that there is a manager or caregiver available as back-up to provide assisted living services to a resident if the manager or caregiver assigned to work is not available or not able to provide the required assisted living services." 2. In an interview, E1 reported two personnel members would be the back-up caregivers. E1 reported the personnel members live in Phoenix and not in Prescott Valley. E1 reported a registered nurse who lives in Prescott Valley would come to AL11324 as a back-up to provide assisted living services. 3. A review of facility documentation revealed staffing schedules for August 2023 and September 2023. However, the staffing schedules for August 2023 and September 2023 did not document the two personnel members who live in Phoenix and the registered nurse who lives in Prescott Valley as back-up personnel. 4. In an interview, E1 acknowledged a plan was not implemented to ensure the manager or a caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of the individual's in-service education required by policies and procedures, for two of five personnel records sampled. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" (dated March 10, 2023). The policy stated "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter." 2. A review of E4's (hired in February 2023) and E5's (hired in February 2023) personnel records revealed E4 and E5 were hired as assistant caregivers. E4's and E5's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported E4 and E5 received a verbal training in fall prevention and fall recovery. E1 acknowledged a personnel record for each employee or volunteer did not include documentation of the individual's in-service education required by policies and procedures.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for two of five personnel records sampled. Findings include: A.R.S. \'a7 36-411(C)(1) Owners shall make documented, good faith efforts to: Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 1. A review of E4's (hired in February 2023) and E5's (hired in February 2023) personnel records revealed E4 and E5 were hired as assistant caregivers. 2. A review of E4's and E5's personnel records revealed documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review. 3. In an interview, E1 reported E4's and E5's previous employers were contacted; however, this information was not documented. 4. In an interview, E1 later reported E4 and E5 did not have previous employment. 5. In an interview, E1 acknowledged E4's and E5's documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of three residents sampled. Findings include: 1. A review of R3's medical record revealed a service plan for personal care services (dated in July 2023). The service plan stated the following service was to be provided to R3: "Requires positioning Q2-3 hrs." 2. A review of R3's medical record revealed an activities of daily living (ADL) sheet for September 2023. The ADL sheet documented "Turn in bed (T)" on September 1-5, 2023 at 7:00PM and on September 6-12, 2023 at 9:00PM. However, "Requires positioning Q2-3 hrs" was not documented in R3's medical record as provided every 2-3 hours on September 1-12, 2023. 3. In an interview, E1 reported the aforementioned service was provided to R3. 4. In an interview, E1 acknowledged a caregiver or assistant caregiver did not documented the services provided in R3's medical records.

Based on record review, documentation review, observation and interview, the manager failed to ensure a medication administered to a resident was administered compliance with a medication order, for one of three 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 R1's (admitted in 2022) medical record revealed a service plan, dated in July 2023. The service plan stated R1 received medication administration. 2. A review of R1's medical record revealed two medication orders, dated April 3, 2023 and April 22, 2023, for the following medication: -Quetiapine 25 MG - 1 tab daily 3. A review of facility documentation revealed a medication administration record (MAR) dated September 2023. The MAR revealed R1 was administered the following medication: -Quetiapine 50 MG - 1 tab at 8 PM between September 1 - September 13, 2023 4. The Compliance Officers observed a bottle of Quetiapine Tab 50 MG, prescribed to R1 and dispensed on August 27, 2023. 5. In an interview, E1 reported the medication orders were created by the facility and signed by R1's doctor. E1 reported the medication orders contained errors and the medication prescribed to R1 was always Quetiapine Tab 50 MG, never 25 MG. E1 acknowledged the facility had administered Quetiapine Tab 50 MG and the medication order, signed by the doctor, was Quetiapine 25 MG.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. The Compliance Officers observed the following medication in an unlocked kitchen cabinet: -Polyethylene Glycol (belonging to R4) 2. The Compliance Officers observed the following medications on a table, in a basket, in R3's bedroom: -Two tubes of Cortizone-10 Maximum Strength cream 3. The Compliance Officers observed several ambulatory residents on the premises. 4. In an interview, E1 acknowledged the medications in the kitchen cabinet and in R3's bedroom were unlocked, accessible to residents, and were not stored in a separate locked room, closet, cabinet or self-contained unit.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area and were inaccessible to residents. Findings include: 1. The Compliance Officers observed an unlocked cabinet in the kitchen. The cabinet contained the following poisonous or toxic materials: -Clarus Tolnaftate 1% The bottle contained a toxic warning label. 2. The Compliance Officers observed an unlocked medicine cabinet in R2's private bathroom. The cabinet contained the following poisonous or toxic materials: -Glade air freshener The bottle contained a toxic warning label. 3. The Compliance Officers observed an unlocked cabinet in R3's private bathroom. The cabinet contained the following poisonous or toxic materials: -Behr Interior Wall Wipes -Disinfecting Spray The bottles contained toxic warning labels. 4. The Compliance Officer observed several ambulatory residents on the premises. 5. In an interview, E1 acknowledged the unlocked materials in the kitchen and bathrooms were accessible to residents. E1 reported there were 4 ambulatory residents in the facility.

Based on documentation review, record review, and interview, 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 effect of the opioid administered, for one of one resident sampled who received an opioid and was not considered to be end-of-life. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Part III - Medication Administration, Records and Monitoring" (dated March 10, 2023). The policy and procedure stated "B. ... 3. Facility personnel will provide opioid medication based on doctor's orders for regular administration (on a regular basis) and will identify and document the level of pain and/or the resident's need for the opioid medication. ... 4. The facility personnel authorized to provide assistance to medication administration or medication administration are to use common sense and verbal and nonverbal communication techniques to identify the residents need for the opioid by assessing level of pain the resident may be experiencing. Examples of such techniques could be: face expression recognition, moaning with movement ... etc. This identification of the resident's need for the opioid must be documented in the NAR. 5. All residents who are subject to receiving opioid medication will have their response to the opioid monitored by checking on the resident within the first half hour after administration, and/or at two hours after administration, and/or then at 4 hours, or as often as is common sense and as the particular case requires. Effectiveness of the opioid administered will be documented in the NAR at the two hour mark or every time a check has been performed. ... 7. Documentation of the assessment and monitoring is documented on the Narcotic Administration Form ... by the caregiver that administered or assisted the resident with self-administration." 2. A review of R3's medical record revealed a service plan for personal care services (dated in July 2023). The service plan revealed R3 received medication administration. 3. A review of R3's medical record revealed a medication order for "Oxycontin CR 10mg 1 Tab TID P.O." (dated August 7, 2023). 4. A review of R3's medical record revealed a medication administration record (MAR) for September 2023. The MAR revealed "Oxycontin CR 10mg 1 Tab TID P.O." was documented as administered on the following dates and times: -September 1-12, 2023 at 8:00AM, 12:00PM, and 8:00PM. However, documentation to include an identification of R3's need for the opioid before the opioid was administered and the effect of the opioid administered was not available for review. 5. A review of R3's medical record revealed evidence of a "Narcotic Administration Form" as described in the facility's policies and procedures for the medication "Oxycontin CR 10mg" was not available for review. 6. In an interview,