Tranquil Living Care Home

Based on record review and interview, the health care institution failed to administer a training program that included initial training and continued competency training in 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 revealed a hire date of January 1, 2024. Documentation showed completion of a training program titled “Fall Prevention.” However, the documentation did not outline that fall recovery training was completed as part of the training. 2. A review of E2's personnel record revealed a hire date of May 22, 2024. Documentation showed completion of a training program titled “Fall Prevention.” However, the documentation did not outline that fall recovery training was completed as part of the training. 3. In an interview, R1 indicated that R1 thought fall prevention was the only required component and did not identify fall recovery as a requirement. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the inspections conducted on August 8, 2024, and April 27, 2023.

Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident that included the information prescribed in subsection A of this section, for two of two residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1 and R2's medical records revealed documentation of the standardized EMS form however, it did not include the following: Whether the resident receives medication services and, if the resident had provided this information to the assisted living center, a list of all the resident's prescription and over-the-counter medications, their dosages, and how frequently they were administered; The name, address, and telephone number of the resident's current pharmacy; A list of any known allergies to any medications, additives, preservatives, and materials like latex or adhesive; Basic information about the resident's physical and mental conditions and basic medical history, as well as dates of recent episodes, if known; The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number, and email address; 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 resident's discharge; A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. 2. In an exit interview, findings were reviewed with E1, and no additional information was provided. 3. Technical assistance was provided regarding this rule during the inspection conducted on August 8, 2024.

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 a three-year review page. However, the page was not signed. 2. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 3. This is a repeat deficiency from the inspection conducted on April 27, 2023.

Based on observation and interview, the manager failed to ensure there was 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 provided access to an outside area 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 general or specific whereabouts of a resident. Findings Include: 1. The facility was licensed at the directed care level. 2. During an environmental inspection of the facility with E1, the Compliance Officer observed that the door in the kitchen leading to the backyard was unlocked, and the alarm was inactive. The door was not monitored. 3. In an exit interview. The findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on August 8, 2024.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed that the facility provided medication administration services. 2. A review of the facility's policies and procedures revealeda policy titled “Medication policies.” However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for four of four personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E1's, E3's and E4's personnel records revealed no documentation of Fall Prevention and Fall Recovery training. 2. A review of E2's personnel record revealed continued education training on Fall Prevention dated March 15, 2024. However no documentation of Fall Recovery training was available for Compliance Officer review. 3. In an interview, E2 acknowledged documentation of Fall Prevention and Fall Recovery training was not available for review for E1, E2, E3, and E4. This is a repeat citation from the on-site compliance inspection conducted on April 27, 2023.

Based on documentation review, record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for two of four personnel sampled. The deficient practice posed a risk if E3 and E4 were a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "Owners shall make documented, good faith efforts to: Verify the current status of a person's fingerprint clearance card." 2. A review of the facility's personnel schedule for the month of August 2024 revealed E3 and E4 were scheduled to work. 3. A review of E3's and E4's personnel records revealed documentation of fingerprint clearance cards (FPCC). Both FPCCs were dated prior to E3's and E4's hire date of record, however no documentation of FPCC verification was available for Compliance Officer review. 4. In an interview, E2 acknowledged that E3's and E4's FPCC cards were not verified, and the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.

Based on documentation review, 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 three of four personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs as the facility had not established or documented a policy and procedure to clarify the health care institution's practice. Findings include; 1. A review of the facility's personnel schedule for August 2024 revealed E2, E3 and E4 were scheduled to work, and provide services in the month of August 2024. 2. A review of E2's, E3's, and E4's personnel records revealed no documentation of verification of E2's, E3's, and E4's skills and knowledge prior to providing health services. 3. E2 acknowledged verification of skills and knowledge was not documented in E2's, E3's, and E4's personnel records before E2, E3, and E4 provided health services.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for one of four personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E3's personnel record revealed a hire date of January 1, 2024. 4. A review of E3's personnel record revealed a negative TB skin test that was more than 12 months old and no additional documentation of freedom from infectious TB was available for review. 5. In an interview, E2 acknowledged E3 did not provided evidence of freedom from infectious TB as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection conducted April 27, 2023.

Based on documentation review and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Resident Rights." The policy stated, "The manager shall ensure that a resident is treated with dignity, respect and consideration." 2. In an interview, E2 self-reported an incident with R3 in which E2 reported speaking aggressively and explicitly towards R3 in a moment of frustration. E2 acknowledged R3 was not treated with dignity, respect, and consideration.

Based on record review and interview, the manager failed to ensure that a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1 for one of three residents sampled. The deficient practice posed a risk as the Department was unable to verify services were provided to R3. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical record as follows... If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The Compliance Officers requested to review R3's medical record. However the entirety of R3's medical record was unavailable for Compliance Officer review. 3. In an interview, E2 reported R3's medical record was stored at another location by E1. E2 acknowledged R3's medical record was not maintained according to A.R.S. Title 12, Chapter 13, Article 7.1.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for one of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's medical record revealed R1 received medication administration. 2. A review of R1's medical record revealed unsigned medication orders for: - Divalproex Sodium 125 milligrams (mg), 1 tablet by mouth (po) twice a day (bid) (dated January 19, 2024); - Trazodone 100 mg, 1 tablet po at bedtime (qhs) (dated November 11, 2023); and - Senna 8.6 mg, 1 tablet po bid (dated November 11, 2023). 3. A review of R1's medication administration record (MAR) for August 2024 revealed the administration of the following medications: - Divalproex Sodium 125 mg, 2 tablets po qd and indicated 2 tablets were administered at 8:00AM August 1 - present; - Trazodone 100 mg, 1 tablet po qhs and indicated 1 tablet was administered at 8:00PM August 1 - present; and - Senna 8.6 mg, 1 tablet po bid, and indicated 1 tablet was administered at 8:00AM and 8:00PM August 1 - present. 4. The Compliance Officers observed the following medications stored by the facility for administration to R1: - Divalproex Sodium 125 mg; - Trazodone 100 mg; and - Senna 8.6 mg. 5. In an interview, E2 acknowledged R1's medical record did not contain a medication order from a medical practitioner for each medication that was administered to the resident.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled 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 general or specific whereabouts of a resident. Findings include: 1. A review of the facility's license revealed that the facility was authorized to provide directed care services. 2. During an environmental tour of the facility, the Compliance Officers observed the front door, sliding back door to the patio, and the door to the backyard from a resident's room were not equipped with an alarm to alert employees of egress. 3. In an interview, E2 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review, observation and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order for one of three residents sampled. 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 R1 received medication administration. 2. A review of R1's medical record revealed an unsigned medication order dated January 19, 2024 for Divalproex Sodium 125 milligrams (mg), 1 tablet by mouth (po) twice a day (bid). 3. A review of R1's medication administration record (MAR) for August 2024 revealed R1 received Divalproex Sodium 125 mg 2 tablets po every day (qd) and indicated two tablets were administered at 8:00AM August 1 - present. 4. The Compliance Officers observed one Divalproex Sodium 125 mg tablet prefilled in the AM slot of R1's medication organizer for August 9 - August 12, 2024. 5. In an interview, E2 acknowledged R1 was not administered Divalproex Sodium 125 mg in compliance with a medication order.

Based on record review, observation, and interview, the manager failed to ensure that medication administered to a resident was accurately documented in the resident's medical record for one of three residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's and R2's medical records revealed R1 received medication administration. 2. A review of R1's medical record revealed an unsigned medication order dated January 19, 2024, for Divalproex Sodium 125 milligrams, 1 tablet per mouth (po) twice a day (bid). 3. A review of R1's medication administration record (MAR) for August 2024 documented the administration of Divalproex Sodium 125 mg, 2 tablets po daily (qd) and indicated two tablets were administered at 8:00AM August 1 - present. 4. The Compliance Officers observed 1 tablet of Divalproex Sodium 125 mg prefilled in the AM slot of R1's medication organizer for August 9 - August 12, 2024. 5. In an interview, E2 acknowledged documentation of the medication administration of Divalproex Sodium 125 mg to R1 was not accurately recorded in R1's MAR.

Based on documentation review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery which posed a health and safety risk to residents, for two of two sampled personnel records reviewed. Findings include: 1. Review of the facility's documents revealed no documented evidence the fall prevention and fall recovery training program had been implemented for all staff. 2. Reviewed of the two sampled caregiver personnel records revealed there was no documentation that E1 and E2 had completed the required training. 3. In an interview, E1 acknowledged the facility did not have documentation that these sampled staff had completed the required fall prevention and fall recovery training as required.

Based on observation, documentation review, and interview, the manager failed to establish, document, and implement a policy and procedure to protect the health and safety of a resident that cover methods by which an assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide which is a health and safety risk. Findings include: 1. The compliance officer observed residents residing at the facility. 2. The compliance officer requested and was not provided with the facility's policy and procedure that cover the methods by which the facility was aware of the general whereabouts of a resident. 3. In an interview, E1 acknowledged there was no policy and procedure that covered the whereabouts of all the assisted living residents at the facility.

Based on document review and interview, the manager failed to ensure the policies and procedures were reviewed at least once every three years and updated as needed. Findings include: 1. In an interview, the compliance officer requested and was not provided documented evidence the manager had reviewed the facility's policies and procedure at least every three years. 2. During an interview, E1 and E2 acknowledged there was no documented evidence the facility's policies and procedures had been reviewed by the manager at least once every three years and updated as needed.

Based on observation, record review, documentation review, and interview, the manager failed to establish and document a policy and procedure as part of the required policies and procedure required in R9-10-803(C)(1)(h) to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services which posed a health and safety risk. Findings include: 1. Review of the facility's documentation revealed the facility had not established, documented, and implemented a policy and procedure to ensure the manager or caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work became unavailable to work. The facility has two residents residing at the facility. 2. In an interview, E1 acknowledged there was no policy and procedure that covered the back-up staffing.