Provide Assisted Living Home

Based on observation, and interview, the manager failed to ensure a complete personnel record was available for one of three personnel sampled. The deficient practice posed a risk as required information could not be verified for E3, and the department was provided false and misleading information. Findings include: 1. Upon arrival at 8:05 AM, the Compliance Officer observed E2 and E3 at the facility. E1 and E4 arrived at the facility around 8:20 AM. 2. In an interview, when questioned about the "Name" and "Title" of E3, E2 reported there was no other personnel in the facility. E2 also reported to be unaware of E3's identity and refused to provide any information to the Compliance Officer. 3. In an interview, the Compliance Officer questioned E1 about the "Name" and "Title" of E3. E1 reported being unaware that there was another personnel member in the facility. 4. During the environmental tour, the Compliance Officer was looking for E3, however E3 had left the facility upon arrival of the Compliance Officer. 5. In an interview, O1 reported E3 was a "Caregiver" and provided the name of E3. 6. In an interview, E1 reported to be unaware that E3 was in the facility; however, E1 acknowledged that E3 was a personnel member. E1 also reported that E3 had no personnel file and that E3's start date was that day (October 04, 2024). 7. In an exit interview, E1 and E4 acknowledged there was no personnel record available for review for E3.

Based on documentation review, observation and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the environmental tour, the Compliance Officer observed an open door leading to the back yard. The Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. The door leading out to the back yard had a functioning chime that was intended to alert employees to the egress of a resident to the outside area. 3. In an interview, E1 reported the door was open for O2 to come in and out of the facility. 4. In an interview, E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure medication stored by the facility was stored in a locked area. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. During the environmental tour, the Compliance Officer observed a refrigerator located in the kitchen. Inside the refrigerator the Compliance Officer observed an unlocked box of "Lorazepam Intensol Oral Concentrate 2 MG", located next to a locked medication box. 2. In an interview, E1 acknowledged medication stored by the facility was not stored in a locked area.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored according to the instructions on the medication container. The deficient practice posed a risk to the integrity of the medication. Findings Include: 1. The Compliance Officer observed a box of "Lorazepam Intensol Oral Concentrate 2 MG" in a medication box with R2's other medications, at room temperature. The Lorazepam box indicated the following storage instructions: "Store at cold temperature. Refrigerate at 2 to 8 degrees Celsius (36 to 46 degrees Fahrenheit)." The Lorazepam was stored in a medication cabinet, at room temperature. 2. In an interview, E1 acknowledged the Lorazepam storage instructions indicated cold storage was required, and acknowledged medication was not stored according to the instructions on the medication container.

Based on observation, documentation review, and interview, the manager failed to ensure pets were licensed consistent with local ordinances. The deficient posed a risk if a pet allowed into the facility did not meet the Maricopa County licensing requirements. Findings include: 1. The Compliance Officer observed O2 roaming throughout the facility during the inspection. 2. A review of facility documentation revealed a pet record for O2 containing a Maricopa County license receipt. However, the license expired in June 22, 2024. 3. In an interview, E1 was unable to provide documentation to indicate O2 was licensed with Maricopa County at the time of the inspection. Technical assistance was provided on this rule during the onsite abbreviation inspection conducted on June 30, 2023.