Sun Health Grandview Assisted Living Services

Based on the record review and interview, the manager failed to ensure that a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented for four of four residents reviewed. Findings include: 1. A review of R1's, R2's, R3's, and R4's medical records revealed no documentation indicating the residents received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility. Based on R1's, R2's, R3's, and R4's date of acceptance, this documentation was required. 2. In an interview, E1 reported that all new residents received orientation to the exits from the assisted living facility as part of the move-in process. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the licensee failed to provide complete acquiescence during the compliance inspection conducted by the Department. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. The Compliance Officer requested to review the following at 9:24 AM: -R6's medical record to include the resident's service plan and updates; and documentation of assisted living services provided to the resident for 2022. 2. The Compliance Officer requested to review the following at 1:08 PM: -R6's medical record to include the resident's service plan and updates; and documentation of assisted living services provided to the resident for 2022. 3. A review of R6's medical record revealed a service plan for directed care services (dated June 2021). However, documentation to demonstrate R6's service plan had been reviewed and updated at least once every three months was not available for review. 4. A review of R6's medical record revealed an activities of daily living (ADL) sheet for October 2022. However, documentation of ADL sheets for January 2022 through September 2022 and November 2022 through December 2022 were not available for review. 5. In an interview, E1 reported R6's updated service plans may be on the previous wellness nurse's computer, however, E1 had not been able to get access to the service plans. 6. In an interview, E1 reported E1 sent R6's medical record to AL10962's lawyers. E1 reported E1 had contacted AL10962's lawyers to provide the aforementioned documentation. However, the lawyers were not responding to E1's inquiries. 7. In an interview, the findings were reviewed with E1 and no additional comments or statements were provided regarding the findings.

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 training. Findings include: 1. A review of facility documentation revealed policies and procedures titled "Fall Prevention" (dated unavailable) and "Post Fall" (date unavailable). However, a fall prevention and fall recovery training program to include initial training and continued competency training was not available for review. 2. A review of E3'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 acknowledged a fall prevention and fall recovery training program to include initial training and continued competency training was not available for review. 4. In an interview, E1 acknowledged a training program for E4 and E5 regarding fall prevention and fall recovery was not administered.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify the health care institution's standards. Findings include: 1. A review of the facility's policies and procedures manual revealed documentation to demonstrate the policies and procedures were reviewed at least once every three years was not available for review. 2. In an interview, E1 reported E1 believed the policies and procedures had been reviewed and updated. 3. In an interview, E1 acknowledged documentation to demonstrate policies and procedures were reviewed at least once every three years was not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation to include the individual's qualifications, including skills and knowledge applicable to the individual's job duties; individual's education and experience applicable to the individual's job duties; the individual's completed orientation required by policies and procedures; and compliance with the requirements in A.R.S. \'a7 36-411(C), for one of five personnel records sampled. Findings include: R9-10-101.165 "Personnel member" means, except as defined in specific Articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient. 1. A review of facility documentation revealed a policy and procedure titled "Employee/Volunteer Orientation" (date unavailable). The policy stated "All employees/volunteers will receive community and department specific orientation to the Grandview Assisted Living-Memory Support on their first day of work." 2. A review of facility documentation revealed a policy and procedure titled "Position Descriptions, Duties, and Qualifications" (date unavailable). The policy stated "2. The knowledge of skills will be validated by the Human Resources department by checking one business reference and one personal reference, along with previous employers, if applicable to ensure that employee can provide services within the facility's scope of services to meet the health and safety needs of the residents" and "3. Certified Caregiver Job Description ... Education and Experience: High School diploma or general equivalency diploma (GED); or one to three months' related experience and/or training; or equivalent combination of education and experience." 3. A review of facility documentation revealed a personnel schedule for September 2023. The schedule revealed E5 was scheduled to work the overnight shift (10:00PM to 6:00AM) the following dates: -September 1-2, 2023; -September 5-9, 2023; -September 11-16, 2023; -September 19-23, 2023; and -September 26-30, 2023. 4. A review of E5's personnel record revealed E5 was hired as a caregiver/medication technician through a temporary staffing agency. 5. A review of E5's personnel record revealed E5's starting date of employment was not available for review. 6. In an interview, E1 reported E5 was hired through a temporary staffing agency. E1 reported E1 would have to check with the temporary staffing agency for E5's starting date of employment with AL10962. 7. A review of E5's personnel record revealed documentation to include the individual's qualifications, including skills and knowledge applicable to the individual's job duties; individual's education and experience applicable to the individual's job duties; the individual's completed orientation required by policies and procedures; and compliance with the requirements in A.R.S. \'a7

Based on observation, record review, and interview, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive, for two of four current residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: A.R.S. \'a7 36-401.48 "Supervisory care services" means general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.39 "Personal care services" means assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.16 "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. The Compliance Officer observed R1 in the memory care area of AL10962. 2. A review of R1's medical record revealed a service plan (dated in April 2023). However, the level of service R1 was expected to receive was not available for review. 3. In an interview, E1 reported R1 was expected to received directed care services. 4. A review of R4's medical record revealed a service plan (dated in May 2023). However, the level of service R4 was expected to receive was not available for review. 5. In an interview, E1 reported R4 was expected to received directed care services. 6. In an interview, E1 acknowledged R1's and R4's service plans did not include the level of service R1 and R4 were expected to receive.

Based on observation, record review, and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three (3) months, for two of two residents sampled who received directed care services; and at least once every six (6) months, for two of three residents sampled who received personal care services. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. Findings include: 1. The Compliance Officer observed R1 in the memory care area of AL10962. 2. A review of R1's medical record revealed a service plan (dated in April 2023). However, the level of service R1 was expected to receive was not available for review. 3. In an interview, E1 reported R1 was expected to received directed care services. 4. A review of R1's medical record revealed documentation to demonstrate R1's service plan had been reviewed and updated at least once every 3 months was not available for review. 5. A review of R2's medical record revealed a service plan for personal care services (dated August 2022). However, documentation to demonstrate R2's service plan had been reviewed and updated at least once every 6 months was not available for review. 6. A review of R3's medical record revealed a service plan for personal care services (dated February 2022). However, documentation to demonstrate R3's service plan had been reviewed and updated at least once every 6 months was not available for review. 7. A review of R6's medical record revealed a service plan for directed care services (dated June 2021). However, documentation to demonstrate R6's service plan had been reviewed and updated at least once every 3 months was not available for review. 8. In a joint interview, E1 and E6 reported updated and current service plans for R1, R2, R3, and R6 were not available for review. 9. In an interview, E1 acknowledged documentation to demonstrate R1's and R6's service plans had been reviewed and updated at least once every 3 months was not available for review. 10. In an interview, E1 acknowledged documentation to demonstrate R2's and R3's service plans had been reviewed and updated at least once every 6 months was not available for review.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for two of two residents sampled who received directed care services; and for two of three residents sampled who received personal care services. The deficient practice posed a risk as a service plan directs the services to be provided to a resident. . Findings include: 1. The Compliance Officer observed R1 in the memory care area of AL10962. 2. A review of R1's medical record revealed a service plan (dated in April 2023). However, the level of service R1 was expected to receive was not available for review. 3. In an interview, E1 reported R1 was expected to received directed care services. 4. A review of R1's medical record revealed documentation to demonstrate R1's service plan had been reviewed and updated at least once every three months was not available for review. 5. A review of R2's medical record revealed a service plan for personal care services (dated August 2022). However, documentation to demonstrate R2's service plan had been reviewed and updated at least once every six months was not available for review. 6. A review of R3's medical record revealed a service plan for personal care services (dated February 2022). However, documentation to demonstrate R3's service plan had been reviewed and updated at least once every six months was not available for review. 7. A review of R6's medical record revealed a service plan for directed care services (dated June 2021). However, documentation to demonstrate R6's service plan had been reviewed and updated at least once every three months was not available for review. 8. In a joint interview, E1 and E6 reported updated and current service plans for R1, R2, R3, and R6 were not available for review. 9. In an interview, E1 acknowledged documentation to demonstrate R1's and R6's service plans had been reviewed and updated at least once every three months was not available for review. 10. In an interview, E1 acknowledged documentation to demonstrate R2's and R3's service plans had been reviewed and updated at least once every six months was not available for review.

Based on documentation review, record review and interview, the manager failed to ensure when a resident had an accident, emergency, or injury resulting in the resident needing medical services, a caregiver or assistant caregiver documented the action taken to prevent the accident from occurring in the future. Findings include: 1. A review of facility documentation revealed a document for an incident involving R1 occurring on April 26, 2023 at 4:45AM. The document stated R1 had an unwitnessed fall resulting in a "cut/bleeding from nose." However, any action taken to prevent the accident, emergency, or injury from occurring in the future was not available for review or indicated on the document. 2. A review of R1's medical record revealed emergency hospital discharge instructions. The instructions revealed R1 was admitted to the emergency department on April 26, 2023 at 5:29 AM. 3. In an interview, E1 acknowledged actions taken to prevent the accident, emergency, or injury from occurring in the future were not documented.