Sarah's Place at Glencroft

Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was licensed for directed care. 2. During the environmental inspection of the facility, the Compliance Officer observed that a door with an alarm was not functioning. 3. In an interview, E1 acknowledged that the door alarm was not functioning and would not alert employees of the egress of a resident.

Based on observation and interview, the manager failed to ensure that medication was stored in a locked room. Findings include: 1. During an environmental inspection, the Compliance Officer was able to open a door to the med room. The room contained used syringe containers on the floor. The room also contained a small fridge that had Lorazepam syringes. 2. In an interview, E1 acknowledged that the med room was unlocked and provided easy access to residents.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual. Findings include: 1. A review of facility documentation revealed a policy titled "Managing Abusive, Aggressive, and Combative Residents." The policy stated "9. Once the immediate situation has been handled, contact the Assisted Living Manager of the Community. The Manager will then contact the Resident's family and medical practitioner to determine the cause of the behavior and to seek a solution to prevent it from happening again." 2. A review of R3's and R4's medical record revealed a report titled "Incident #1641" for R3 and R4 dated October 19, 2024. The document revealed where R4 displayed sudden, intense or out control behavior, immediate action taken by caregivers to deescalate the situation, personal and representatives the incident was reported per instructions provided, and actions completed by the care coordinator. However, no documenation that a medical practitioner was contacted as per policy was available. 3. In an interview, E1 acknowledged that policies and procedures were not implemented to protect the health and safety of a resident to include how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual.

Based on record review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to initiate an investigation of the suspected abuse, neglect, or exploitation and document the information. The deficient practice posed a risk of the suspected abuse occurring in the future. Findings include: 1. A review of R3's and R4's medical record revealed a report titled "Incident #1641" for R3 and R4 dated October 19, 2024. The document revealed a reasonable basis to believe abuse occurred on the premises, immediate action taken by caregivers to stop the suspected abuse, personnel and representatives the incident was reported to per instructions provided, and actions completed by the care coordinator. However, the report was completed by caregiver personnel and did not include an investigation being initiated by the manager. 2. In an interview, E1 reported the facility took action terminating R4's residency in the facility. E1 acknowledged that after having a reasonable basis to believe abuse occurred on the premises, the manager failed to initiate an investigation of the suspected abuse, neglect, or exploitation and document.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan, for one of three residents sampled. Findings include: 1. A review of R1's medical records revealed a document titled "Direct Level of Care Service Plan" dated October 24, 2024. The service plan stated "Bathing Assistance: Total Care: Staff will provide hands on assistance with shower, wash body/hair, set up/clean up." R1's service plan revealed bathing frequency to be completed two times per week by hospice. 2. In an interview, E1 reported that R1 was removed from hospice services November 1, 2024. 3. A review of R1's medical record revealed a document titled "ADL Log" used to document completion of R1's activities of daily living to be provided. However, the ADL log revealed that bathing services were not documented as being completed. 4. In an interview, E1 acknowledged R1 had not received bathing services since from November 1 - November 7, 2024. E1 acknowledged the manager failed to ensure a caregiver or assistant caregiver provided assistance with activities of daily living according to the resident's service plan.

Based on record review and interview, a manager failed to ensure a resident was treated with dignity, respect, and consideration for one of three residents sampled. Findings include: 1. A review of R1's medical records revealed a document titled "Direct Level of Care Service Plan" dated October 24, 2024. The service plan stated "Bathing Assistance: Total Care: Staff will provide hands on assistance with shower, wash body/hair, set up/clean up." R1's service plan revealed bathing frequency to be completed two times per week by hospice. 2. In an interview, E1 reported that R1 was removed from hospice services November 1, 2024. 3. A review of R1's medical record revealed a document titled "ADL Log" used to document completion of R1's activities of daily living to be provided. However, the ADL log revealed that bathing services were not documented as being completed. 4. In an interview, E1 acknowledged R1 had not received bathing services since from November 1 - November 7, 2024. E1 reported that hospice had not been removed from the service plan to alert caregivers to complete bathing. E1 acknowledged the manager failed to ensure a resident was treated with dignity.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a residents needs or emergencies was available in a bedroom being used by a resident receiving directed care services or had implemented another means to alert a caregiver or assistant caregiver to a resident's needs or emergencies for three of three directed care residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed resident rooms were not equipped with a bell, intercom, or other mechanical means to alert employees to resident needs or emergencies. Compliance Officers observed pull chords equipped in resident bathrooms, however, the alerts were not operational. 2. A review of R1's, R2's, and R3's medical records revealed that R1, R2, and R3 were to receive directed level of services. 3. In an interview, E1 reported facility personnel complete two hour checks for resident needs or emergencies in lieu of a bell, intercom, or mechanical means. E1 acknowledged the manager failed to ensure a bell, intercom, other mechanical means, or had implemented another means to alert employees to a resident's needs or emergencies in a bedroom being used by a resident receiving directed care services.

Based on record review and interview, the manager failed to ensure that the resident's orientation to the exits within 24 hours after the resident's acceptance was documented for one of three residents reviewed. Findings include: 1. A review of R2's medical record revealed documentation of R2's orientation to exits within 24 hours of acceptance was not available. 2. In an interview, E4 reported that orientation to the facility exits was conducted with R2's family at the time of move in. E4 acknowledged that R2's orientation to the exits within 24 hours after the resident's acceptance was not documented.

Based on record review, and interview when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or assistant caregiver immediately notified the resident's emergency contact and primary care provider for two of three residents reviewed. Findings include: 1. A review of R1's medical record revealed an incident report for incident #1641. The incident report revealed R1 had been injured in the incident and contact was made with the facility's manager, director, medical director, 911, and with R1's representative. However, no documentation of contact with R1's primary care provider was available. 2. A review of R4's medical record revealed an incident report for incident #1641. The incident report documented R4 had been sent out for medical services. However, no documentation of contact with R4's primary care provider was available. 3. In an interview, E1 acknowledged that when a resident had an accident, emergency, or injury that resulted in the resident needing medical services, the manager failed to ensure that a caregiver or assistant caregiver immediately notified the resident's primary care provider.

Based on documentation review, 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 to include continued competency. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of facility's documentation revealed a policy and procedure titled "Fall Prevention Program (AL)" (dated March 22, 2023). However, a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency was not available for review 2. A review of E5's and E6's personnel records revealed documentation of initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 reported a training in fall prevention and fall recovery had not been administered recently. 4. In an interview, E1 acknowledged a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency was not available for review. 5. In an interview, E1 acknowledged documentation to demonstrate E5 and E6 were administered training regarding fall prevention and fall recovery was not available for review.

Based on documentation review, record review, and interview, the manager failed to immediately report suspected abuse according to A.R.S. \'a7 46-454. The deficient practice posed a risk as a peace officer or the adult protective services central intake was unable to assess if there was an immediate health and safety concern for the resident and other residents residing in the assisted living facility. Findings include: A.R.S. \'a7 46-454(A) ... other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services (APS) central intake unit ... All of the above reports shall be made immediately by telephone or online. A.R.S. \'a7 46-454(B) If an individual prescribed in subsection A of this section is an employee or agent of a health care institution as defined in section 36-401 and the health care institution's procedures require that all suspected abuse, neglect and exploitation be reported to adult protective services as required by law... R9-10-101(110) "Immediate" means without delay. 1. A review of documentation revealed a complaint was received by the Department on July 31, 2023. The complaint alleged sexual misconduct between two residents (later identified as R2 and R4). 2. A review of facility documentation revealed documentation of an incident reported by E7 (dated July 9, 2023). The report stated "I was doing rounds when I saw the [R4] sitting on the bed with the other [R2] resident brief opened and the blanket on the side of [R2]. [R4] had [R4's] hand in [R2's] private area" and "Glendale police was called by the POA and a report was created." However, documentation to demonstrate AL8862 immediately reported the suspected abuse, neglect, and exploitation according to A.R.S. \'a7 46-454 was not available for review. 3. A review of facility documentation revealed a policy and procedure titled "Abuse, Neglect of Exploitation Prevention and Reporting" (dated June 13, 2023). The policy stated " If abuse, neglect or exploitation of a resident is alleged or suspected to have occurred on the premises or while the resident is receiving services from the facility staff, the manager shall: ... 2. Immediately report the alleged or suspected abuse, neglect or exploitation of the resident according to A.R.S. \'a7 46-454." 4. A review of facility documentation revealed a policy and procedure titled "Orientation and In-Service Training for Employees and Volunteers" (dated June 13, 2023). The policy stated "All employees and any volunteer who works has or is [sic] expected to have more than 8 hours per week of direct interaction with residents will be provided orientation that is specific to the duties to be performed prior to providing service to any Resident of the Community. Topics may include but not limited to: .

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of one individual sampled who was hired a caregiver. The deficient posed a risk if E2 was not trained to provide the required services. Findings include: 1. A review of facility documentation revealed a staffing schedule for August 2023. The schedule revealed E2 was scheduled to work from 6:30AM to 3:00PM, with another employee, on the following dates: -August 1-5, 2023; -August 8-12, 2023; -August 15-19, 2023; -August 22-26, 2023; and -August 29-31, 2023. 2. A review of E2's (hired in 2023) personnel record revealed E2 was hired as a caregiver. E2's personnel record revealed documentation of a certificate of successful completion from the Arizona State Board of Nursing approved Nurse Aide Training Program from 8910-Medstar Academy (dated June 20, 2023). 3. A review of the NCIA Board website for caregiver training programs (https://nciaboard.az.gov/news/caregiver-certificate-verification) revealed a training program ALTP# 172 Medstar Academy Inc. was in operation from November 10, 2010 to August 2, 2013. 4. A review of https://az.tmuniverse.com revealed E2 had not completed a caregiver training program. 5. In a joint interview, the findings were reviewed with E1 and E8 and no additional comments or statements were provided regarding the findings.

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 three of seven personnel records sampled. The deficient practice posed a risk if E2, E5, and E6 were a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(C) Owners shall make documented, good faith efforts to: 1. 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 E2's (hired as a caregiver), E5's (hired as an assistant caregiver), and E6's (hired as a caregiver) personnel records revealed documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review. 2. In an interview, E1 reported documentation to demonstrate E2's, E5's, and E6'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 medication was administered in compliance with a mediation order, for one of two current residents sampled who received medication administration. 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 medical record revealed a current service plan for directed care services (dated in 2023). The service plan revealed R1 received medication administration. 2. A review of R1's medial record revealed a medication order for "Memantine 10mg Tab Take one (1) tablet by mouth every morning and evening" (dated November 16, 2022). 3. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. The MAR stated "Memantine HCl 10mg tabs Take one tablet by mouth every morning and evening." R1's MAR revealed Memantine was not documented as administered, as the medication was not available on the premises, on the following dates: -August 1-4, 2023; -August 8-12, 2023; -August 14-15, 2023; and -August 18-21, 2023. 4. In an interview, E1 reported R1's medical practitioner was based in a town in northeast Arizona and would dispense the medication once the insurance approved the medication. E1 reported R1's family would then pick up the medication and physically deliver the medication to AL8862. 5. In an interview, E1 reported R1's medical practitioner has not indicated any concern with the missed medication. 6. In an interview, E1 acknowledged medication was not administered in compliance with a medication order.