Rising Rainbow Care Home LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Review Timeframe for Policies and Procedure." The policy stated "Policy and Procedure manual to be reviewed updated and approved by manager at least once every three years and updated as needed." However, documentation to indicate the policies and procedures were reviewed and updated as needed was not available for review. 2. In an interview, E2 acknowledged E1 failed to ensure policies and procedures were reviewed and updated at least once every three years.

Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge. Findings include: 1. A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. During the environmental tour, the Compliance Officer observed resident medical records were openly visible, sitting on a bookshelf located at the entrance of the facility. 3. In an interview, E2 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could 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 facility staff were unaware of the egress of a resident from the facility. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed two ambulatory residents. 3. During the environmental tour, the Compliance Officer observed the front door leading to the street from the facility. However, the door was not secured and the door chime was not functioning. 4. During the environmental tour, the Compliance Officer observed a sliding door located in the living room leading to the back yard. However, the door was not secured and there was no device to alert employees. 5. During the environmental tour, the Compliance Officer observed a garage door leading to the back yard. However, the door was not secured and there was no device to alert employees. 6. A review of facility documentation revealed a policy titled "Environmental and Physical Plant Safety," the policy stated "4. Exit doors and windows to the outside that a wandering resident may exit through, will be alarmed to alert employees in the event a resident is wandering." 7. In an interview, E2 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility. 8. In a telephonic interview, E1 acknowledged there were means of exiting the facility to an outside area which did not control or alert employees of the egress of a resident from the facility.

Based on observation, documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During the environmental tour, the Compliance Officer observed the facility provided medication administration services. 2. A review of facility documentation revealed a policy titled, "Medication Including Opioids and Narcotics." However the medication services policy and procedure was not reviewed and signed by a medical practitioner, registered nurse, or pharmacist. 3. In an interview, E2 acknowledged the medication services policy and procedure was not reviewed and signed by a medical practitioner, registered nurse, or pharmacist.