Spring Assisted Living, LLC

Based on documentation review and interview, the manager failed to ensure that 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. A review of the facility's policy and procedure manual revealed documentation of a review of the facility's policies and procedures on November 5, 2019. However, no additional documentation of review was available for Compliance Officer review. 2. In an interview, E1 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on observation, record review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk if the individuals were not trained to provide the required services. Findings include: 1. While on-site for the compliance inspection, the Compliance Officers observed E2 alone in the facility and providing services to residents. 2. A review of E2's personnel record revealed a job title of "Assistant Caregiver." E2's personnel record did not contain documentation of a completed caregiver training program. 3. In an interview, E1 reported E2 was an assistant caregiver, and did not possess a caregiver certificate. E1 acknowledged E2 interacted with residents without the supervision of a manager or caregiver.

Based on record review and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for two of two personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include: 1. A review of the facility's employee schedule for October 2024 revealed E1 and E2 were scheduled to work and provide services in the month of October 2024. 2. A review of E1's and E2's personnel records revealed no documentation of verification of E1's and E2's skills and knowledge prior to providing health services. 3. In an interview, E1 acknowledged verification of skills and knowledge was not documented in E1's and E2's personnel records before E1 and E2 provided health services.

Based on documentation review, record review and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d) for two of three residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of the facility's policies and procedures revealed a policy titled, "Infection Control: Influenza / Pheumonia [sic]." The policy stated, "A manager shall ensure that upon acceptance of a resident to Spring Assisted Living LLC, the resident or representative is aware of the availability of the Influenza vaccine / Pneumonia vaccine and may elect whether or not to inoculation [sic]... This requirement shall be done approximately every 12-months... The request or declination shall be properly documented on a proper form entitled 'FLU/PNEUMO VACCINE ELECTION" which is provided by the Facility when the resident is admitted and signed by the resident or representative upon acceptance." 3. A review of R1's medical record revealed R1 received the flu vaccine November 1, 2022; however, documentation was not available that indicated whether the pneumonia vaccine was received or refused. Based on R1's acceptance date, this documentation, as well as additional offering documentation, was required. 4. A review of R3's medical record did not include documentation that indicated R3 was offered the flu or pneumonia vaccines. Based on R3's acceptance date, this documentation was required. 5. In an interview, E1 acknowledged R1's and R3's medical records did not contain documentation of R1's and R3's notification of the availability of vaccinations according to A.R.S. \'a7 36-406(1)(d).

Based on documentation review, observation, and interview, the manager failed to ensure that policies and procedures were implemented for discarding medication including expired medication. The deficient practice posed a risk as the standards expected of employees were not followed. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Disposal." The policy stated, "A manager shall ensure that a resident's medication shall be disposed of according to state and federal regulations and established procedure. ... Any meds destroyed by manager [sic] for current and deceased residents must be documented and witnessed by one other [sic] and follow safety guidelines per ADEQ Policies (The use of Plaster or Paris or Cement to discharge meds). All events that require disposing of meds will be handled by the manager or designee, first securing the meds and then disposing of them with 48 hours of notice the resident has expired or will no longer be taking that medication or form of medication." 2. During an environmental inspection of the facility, the Compliance Officers observed a basket of medications stored in an unlocked cabinet in the facility's unlocked laundry room that included: - Pepto Bismol Liquid, with an expiration date of February 2021; - Children's Delsym Cough Syrup; - Theraflu Severe Cough and Cold; and - Robitussin. However, the medication was not prescribed to a specific resident of the facility. 3. In an interview, E1 reported the medication observed was for a previous resident and had not been disposed of. E1 acknowledged the facility's policies and procedures for discarding medication were not implemented.

Based on observation and interview, the manager failed to ensure that oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed oxygen containers unsecured on top of a shelf in the facility's laundry room. 2. In an interview, E1 acknowledged the oxygen containers were not secured.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a container of Lysol Disinfecting Wipes on top of a filing cabinet in the facility's unlocked laundry room. 2. During an environmental tour of the facility, the Compliance Officers observed the following toxic materials stored in an unlocked cabinet in the facility's unlocked laundry room: - Duracraft Exterior Acrylic Paint; - PowerHouse Mop & Shine Floor Cleaner; - LNZ36 Liquid Enzyme; - Air Wick Air Freshener Spray; - Neem Oil Insecticide, Fungicide, Miticide; and - La's Totally Awesome Wool Wash. 3. The Compliance Officers observed the following unlabeled containers stored in an unlocked cabinet in the facility's unlocked laundry room: - An unlabeled spray bottle filled with a transparent yellow liquid; - An unlabeled spray bottle filled with a transparent clear liquid; and - An unlabeled spray bottle filled with an opaque white liquid. 4. The Compliance Officers observed the following toxic materials stored in the facility's unlocked garage: - Glade Air Freshener Spray; - Clorox Disinfecting Wipes; - Lysol Disinfecting Spray; - Spray - N - Wash; - Great Value Low-Splash Bleach; - Clorox Toilet Bowl Cleaner; - Clorox Bleach; and - Kirkland Laundry Detergent. 5. The Compliance Officers observed a container of Kirkland Laundry Detergent stored in the facility's unlocked pantry. 6. The Compliance Officers observed the following toxic materials stored in the facility's unlocked cabinet under the kitchen sink: - Great Value Dishwasher Pacs; - Febreeze Air Freshener Spray; - Ajax Ultra Dish Soap; and - Comet Bleach Powder. The cabinet was equipped with a lock, however, the lock was not functioning at the time of inspection. 7. In an interview, E1 acknowledged the toxic materials stored by the facility were not maintained in labeled containers in a locked area and inaccessible to residents.