Sweet Home Assisted Living

Based on documentation review and interview, the healthcare institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1's personnel record did not include documentation of completed fall prevention and fall recovery training. Based on E1's date of hire, this documentation was required. 2. A review of E2's personnel record did not include documentation of completed fall prevention and fall recovery training. Based on E2's date of hire, this documentation was required.  3. In an interview, E1 acknowledged documentation was not available that showed E1 and E2 completed fall prevention and fall recovery training.  This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available.  2. In an interview, E1 acknowledged documentation was not available that showed the facility had annually assessed the health care institution's risk of exposure to infectious TB.

Based on record review and interview, the healthcare institution failed to document in the patient’s medical record an identification of the patient’s need for the opioid before the opioid was administered, for one of two residents sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of R1’s medical record revealed a signed order, dated January 16, 2025, for Oxycodone HCL 5 milligrams (mg), 2 tablets by mouth (po) twice a day (bid) as needed (PRN) for pain. 2. A review of R1’s medication administration record (MAR) for March 2025, revealed a form titled, “Narcotic Declining Form.” The form revealed R1 was administered Oxycodone 5 mg 2 tablets po at 8:00 AM and 8:00 PM on March 1, 2025 - present. However, the form did not include documentation of R1’s need for the opioid. 3. A review of R1's medical record revealed no documentation stating R1 had an end of life condition or an active malignancy. 4. In an interview, E1 acknowledged that the facility did not document R1’s need for the opioid before the opioid was administered to R1.

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel sampled. The deficient practice posed a risk if E1 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(2) states, "Each residential care institution, nursing care institution, and home health agency 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. 2. While on-site for the compliance inspection, the Compliance Officers observed E1 at the facility, providing services to residents. 3. A review of E1's personnel record did not include documentation of the facility's good faith effort to contact E1's previous employers. 4. In an interview, E1 acknowledged that the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2). This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver’s skills and knowledge were verified and documented before the caregiver provided physical health services, according to policies and procedures, for two of two personnel sampled. The deficient practice posed a risk if the employees were unable to meet a resident's needs. Findings include: 1. A review of the facility's personnel schedule revealed E1 and E2 were scheduled to work and provide services at the facility from March 1, 2025, to March 29, 2025. 2. A review of E1's and E2's personnel records revealed E1 and E2 were hired as a caregiver. 3. A review of E1's and E2's personnel records did not include documentation of verification of skills and knowledge. 4. A review of the facility's policies and procedures revealed no policy that covered documentation of skills and knowledge. 5. In an interview, E1 acknowledged that E1's and E2's personnel records did not include documentation of the verification of E1's and E2's skills and knowledge before E1 and E2 provided physical health services. This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on documentation review, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver received orientation that was specific to the duties to be performed by the caregiver, for one of two sampled caregivers. The deficient practice posed a risk if the employees were unable to meet residents’ needs.  Findings include: 1. A review of the facility's personnel schedule revealed E1 was scheduled to work and provide services at the facility from March 1, 2025, to March 29, 2025. 2. A review of E1's personnel record revealed E1 had been hired as a caregiver. 3. A review of E1's personnel record did not include documentation of E1's completed orientation. 4. In an interview, E1 acknowledged documentation was not available that showed E1 received orientation that was specific to the duties to be performed by E1. This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was signed and dated by the resident or resident’s representative, for one 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 R3's medical record revealed a service plan, dated February 1, 2025. However, the resident or resident's representative did not sign and date the service plan. 2. In an interview, E1 reported R3's representative was not available to sign the service plan. E1 acknowledged R3's service plan was not signed and dated by the resident or resident's representative. This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that 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 R2's medical record revealed a completed service plan, dated December 12, 2024. However, the facility's manager did not sign and date the service plan. 2. A review of R3's medical record revealed a service plan, dated February 1, 2025. However, the facility's manager did not sign and date the service plan. 3. In an interview, E1 acknowledged R2's and R3's service plans were not signed and dated by the facility's manager. This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on record review and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of three residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed a service plan that indicated R1 would receive colostomy care, as needed (PRN). 2. A review of R1's activities of daily living (ADL) documentation for March 2025, did not include documentation of colostomy care. 3. In an interview, E1 reported R1 received assistance with colostomy care once a week. E1 acknowledged that a caregiver failed to document the services provided in R1's medical record. This is a repeat deficiency from the inspection conducted on February 7, 2023.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented that ensure the safety of a resident who may wander. Findings include: 1. A review of the facility's policies and procedures did not include a policy to ensure the safety of a resident who may wander. 2. In an interview, E1 acknowledged policies were not established, documented, and implemented that ensured the safety of a resident who may wander.

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Medication Services." However, the policy had not been reviewed and approved by a medical practitioner, registered nurse, or pharmacist. 2. In an interview, E1 acknowledged the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Based on record review and interview, the manager failed to ensure that a caregiver documented the time of the accident, emergency, or injury, the names of the individuals who observed the accident, emergency, or injury, the actions taken by the caregiver, the individuals notified by the caregiver, and any action taken to prevent the accident, emergency, or injury from occurring in the future, when a resident had an accident, emergency, or injury that resulted in the resident needing medical services. Findings include: 1. A review of R1's medical record revealed R1 had a fall on January 15, 2025, that resulted in R1 needing medical services. However, the documentation did not include the following elements: the time of the accident; the names of individuals who observed the accident; the actions taken by the caregiver; the individuals notified by the caregiver; and any action taken to prevent the accident from occurring in the future. 2. In an interview, E1 acknowledged that when R1 had an accident, emergency, or injury that required medical services, a caregiver did not document all required elements per R9-10-818.D.2.

Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area inaccessible to residents. Findings include: 1. A review of Department records revealed the facility was licensed to provide directed care services. 2. During the environmental inspection, the Compliance Officers observed the following poisonous or toxic materials stored in the unlocked garage: “Silicone” Surface Safe Lubricant spray; Two "Clorox" bottles; “Clorox” Clean Liquid; “Deep Clean- Arm & Hammer Laundry Detergent”; “Raid Ant & Roch” Spray; “Lysol”; Power Clinging Gel; “LA's Totally Awesome” Fabric Refresher; “OdoBan” Eliminates Order Disinfectant Fabric & Air Refresher; "Easy-Off” Cleaner Degreaser Heavy duty; and “Fabuloso” multi-purpose cleaner. 3. During an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents.

Based on observation and interview, the manager failed to ensure that hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a health and safety risk for residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a water temperature of 150º F in R2's bathroom, a water temperature of 133° F in a shared bathroom for residents, and a water temperature of 150° F in the kitchen sink. 2. In an interview, E1 acknowledged hot water temperatures were not maintained between 95º F and 120º F in areas of an assisted living facility used by residents.