Supreme Adult Care Home

Based on documentation review, record review, and interview, the manager failed to ensure that policies and procedures were implemented to protect the health and safety of a resident that covered 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 the facility's policies and procedures revealed a policy titled, "Caregiver's Response to a Resident's Out-of-Control Behavior." The policy stated, "A. If a sudden, intense or out-of-control behavior occurs a caregiver will: ... B. Document the incident using a Behavior Report Form." 2. A review of R1's medical record revealed progress notes from January 25, 2025. The notes stated, "[R1] woke up in a negative mood for unknown reasons. ... [R1] had explosive behavior and attempted to fight the home manager when asked to put a hat on outside because it is very cold." 3. While on-site for the compliance and complaint inspection, the Compliance Officer requested the completed behavior report form in relation to the incident on January 25, 2025. However, a behavior report form had not been completed at the time of the inspection. 4. In an interview, E1 reported E1 had not completed a behavior report form following the incident, and had documented the incident in the aforementioned progress notes. E1 acknowledged the facility's policies and procedures regarding 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 were not implemented.

Based on record review, documentation review, and interview, the manager failed to ensure that a documented report was submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care. Findings include: 1. A review of R2's medical record revealed an incident on December 10, 2024, for which R1 required medical services. 2. A review of the facility's quality management documentation, dated December 30, 2024, indicated the facility did not have any "incidents requiring the response of emergency services" or any "incidents which had the potential to adversely affect the health and/or safety of one or more resident." 3. In an interview, E1 acknowledged the quality management report did not include an identification of each concern about the delivery of services related to resident care.

Based on record review and interview, the manager failed to ensure that before or at time of acceptance of an individual submitted documentation that was dated within 90 calendar days before the individual was accepted by an assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints and was signed and dated by a medical practitioner, for one of three residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officer requested R2's medical record with all required documents at 11:00 AM. However, the medical record provided did not include documentation signed by a medical practitioner that included if R2 required continuous medical services, continuous or intermittent nursing services, or restraints within 90 days before R2 was accepted into the facility. 2. In an interview, E1 acknowledged R2's medical record did not contain documentation signed by a medical practitioner that included if R2 required continuous medical services, continuous or intermittent nursing services, or restraints at the time of acceptance or within 90 days before R2 was accepted into the facility.

Based on documentation review, record review, and interview, the manager failed to ensure that within five working days after a resident's acceptance by the assisted living facility, the manager obtained the signature of the resident's representative on the documented agreement required in subsection (D), for one of three residents sampled. The deficient practice posed a risk if the resident, the resident's representative was not informed of the terms of residency. Findings include: 1. R9-807.D states, "Before or at the time of an individual ' s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility..." 2. A review of R2's residency agreement did not include a signature of R2's representative. Given R2's date of acceptance, this documentation was required. 3. In an interview, E1 acknowledged R2's residency agreement did not include the signature of R2's representative within five working days of R2's acceptance into the facility.

Based on record review and interview, the manager failed to ensure that a resident's written service plan when updated, was signed and dated by the resident's representative, for two of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 12, 2025. However, the service plan was not signed and dated by R1's representative. 2. A review of R2's medical record revealed a service plan, dated January 21, 2025. However, the service plan was not signed and dated by R2's representative. 3. In an interview, E1 acknowledged R1's and R2's updated service plans were not signed and dated by the residents' representatives.

Based on record review and interview, the manager failed to ensure that a resident's written service plan when updated, was signed and dated by the manager, for two of three residents sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed a service plan, dated January 12, 2025. However, the service plan was not signed and dated by the manager. 2. A review of R2's medical record revealed a service plan, dated January 21, 2025. However, the service plan was not signed and dated by the manager. 3. In an interview, E1 acknowledged R1's and R2's updated service plans were not signed and dated by the manager.

Based on record review and interview, the manager failed to ensure a service plan included documentation of the resident's weight or documentation from a medical practitioner stating weighing the resident was contraindicated, for one of three residents sampled. The deficient practice posed a health and safety risk to the residents. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. 2. A review of R1's service plan dated January 12, 2025 did not include documentation of R1's weight. In addition, R1's medical record did not include documentation from a medical practitioner stating weighing R1 was contraindicated. 3. In an interview, E1 acknowledged R1's service plan did not include documentation of R1's weight and documentation was not available in R1's medical record from a medical practitioner stating weighing R1 was contraindicated.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained 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 Officer observed the following materials stored in the facility's unlocked garage: - A container of Behr Paint; and - A container of Glidden Interior Paint. 2. The Compliance Officer observed the following materials stored in an unlocked cabinet, in the facility's unlocked garage: - Comet with Bleach Powder cleaner; - LA's Totally Awesome Mold and Mildew Stain Remover; - Comet Classic Kitchen Cleaner with Bleach; - Scrubbing Bubbles Spray Cleaner; - Great Value Glass Cleaner; - Clorox Bathroom Cleaner; and - Sun-Pine Cleaner with Bleach. 3. In an interview, E1 reported the facility locked the garage to prevent access; however, the area was accessible at the time of inspection. E1 acknowledged that poisonous or toxic materials stored by the facility were not maintained in a locked area and inaccessible to residents.

Based on observation, documentation review, and interview, the manager failed to ensure that dogs were vaccinated against rabies. Findings include: 1. While on-site for the compliance and complaint inspection, the Compliance Officer observed two dogs residing at the facility. 2. The Compliance Officer requested the dog's vaccination records at 11:00 AM. However, documentation of the dog's vaccination against rabies was not available. 3. In an interview, E1 reported the dogs had not been vaccinated against rabies at the time of the inspection due to their age. E1 acknowledged that the dogs residing at the facility were not vaccinated against rabies.

Based on record review and interview, the manager failed to ensure that for two of two residents sampled, a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for each resident. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's and R2's medical records did not contain the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). 2. In an interview, E1 provided a face sheet and additional documentation that is typically sent with emergency responders. However, the documentation did not contain the following required information: -The name, address, and telephone number of the resident's current pharmacy; -A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive; -A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the patient's discharge; and -A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. 3. In an interview, E1 acknowledged the information required in A.R.S. \'a7 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on observation and interview, the manager failed to ensure a qualified caregiver, who had been designated in writing, was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed E2 was the only personnel member present on the premises and working at the facility. E2 immediately called E1 to return to the facility. E2 was unable to provide any documentation to the Compliance Officer and asked the Compliance Officer to wait for E1 to facilitate the inspection. 2. Upon entry, the Compliance Officer observed a posting titled, "Delegation of Authority." However, E2 was not listed on this posting as a manager's designee. 3. In an interview, E2 reported E2 does not administer medication to the residents. E1 reported administering medications makes E2 "nervous" and medication administration was completed only by E1. 4. In an interview, E1 acknowledged the manager failed to ensure a qualified caregiver, designated in writing, was present on the premises and accountable for the assisted living facility when the manager was not present.

Based on documentation review, 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, for one of two personnel records sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work." 2. A review of E2's personnel record revealed E2 was hired March 1, 2024. 3. A review of E2's personnel record revealed no evidence of a fingerprint clearance card. However, there was a fingerprint clearance card application dated May 1, 2024. 4. Upon entering E2's application number into the Arizona Department of Public Safety database, the Compliance Officer discovered the application was received by the Arizona Department of Public Safety on May 9, 2024. Further review revealed the following comment: "Application Complete - Results mailed to applicant." The "Issue Date" and "Expiration Date" of E2's fingerprint clearance card were not provided. 5. In an interview, E1 and E2 acknowledged E2's personnel record did not include a valid fingerprint clearance card. E1 acknowledged E2 did not apply for a fingerprint clearance card within twenty working days of employment as required per A.R.S. \'a7 36-411.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for one of two residents sampled. The deficient practice posed a risk as the service plan to direct services was not followed. Findings include: 1. A review of R1's medical record revealed a service plan dated April 12, 2024 for directed care services. Under the title, "Skin Care" the service plan indicated R1 required the following services: -Keep skin clean & dry and not in contact with the plastic portion of blue pads; -Monitor skin integrity daily; -Hydrate skin with moisturizer lotion daily or PRN to hydrate skin & to prevent skin breakdown; -Precaution thin, frail skin; -Apply skin barrier/protectant as ordered; -Check pressure area daily; -Keep linens clean and free of wrinkles. Wrinkles cause a lot of pressure on an area & will cause open or red skin; -Sufficient fluids & protein intake offers daily; and -Check feet daily. 2. A review of R1's activities of daily living documentation revealed R1's "Skin Condition" was monitored by the facility and documented daily. 3. A review of documentation submitted to the Department reported R1 was provided with peri-hygiene care as there was an odor of uncleanliness to R1. It was noted R1 had thick dried layers of stool and white cream on the peri area, as well as excoriation and chafing in areas with skin-on-skin contact. Once cleaned, R1's skin was raw and bleeding underneath. 4. In an interview, the Compliance Officer inquired as to the condition of R1's skin and peri area as R1 was bedbound. E2 reported R1's skin was in good condition. E1 and E2 reported E2 may have missed some areas under R1's genitalia and groin, but R1's skin was in good condition overall. 5. In an interview, E1 and E2 acknowledged R1 was not provided assisted living services according to R1's service plan, as E2 missed cleaning critical areas during peri-hygiene care.

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. The deficient practice posed a risk as services stated in the residents' service plans were not available. Findings include: 1. A review of R1's medical record revealed service plans dated January 12, 2023; July 12, 2023; and October 12, 2023. The service plans revealed R1 received directed care services. 2. A review of R2's medical record revealed a service plan dated October 12, 2023. The service plan revealed R2 received directed care services. 3. The Compliance Officer requested R1's and R2's current service plans. However, E1 was unable to find R1's and R2's current service plans. E1 made a phone call to O1, who personally delivered R1's and R2's current service plans to the facility. 4. In an interview, E1 acknowledged R1's and R2's medical records did not contain a current service plan until provided by O1.