Vicky's Loving Home

Based on documentation review, and interview, the manager failed to ensure that an assistant caregiver interacted with residents under the supervision of a manager or caregiver for two of two assistant caregivers. The deficient practice posed a risk as the individuals were not qualified to provide the required services. Findings include: 1. A review of Department documentation revealed the facility is licensed at the directed care level. 2. A.R.S. § 36-401.A.42. defines "Supervision" as directly overseeing and inspecting the act of accomplishing a function or activity. 3. Upon arrival at the facility, E3 and E4 were observed as the only employees at the facility. 4. During an interview, E3 reported E1 was not at the facility. E3 called E1 to come to the facility. 5. During the environmental inspection of the facility with E3, the Compliance Officers observed E4 alone while cleaning and doing dishes in the kitchen. The Compliance Officers asked E3 if E3 could open the door to a room with a shut door. E3 reported the resident was sleeping. 6. During an interview, E1 reported that E3 and E4 are assistant caregivers. E2 is the certified caregiver. E1 reported that E2 was in the room with the door closed and watching television. 7. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, documentation review, and interview, the manager failed to ensure that caregiver’s and assistant caregiver’s skills and knowledge were verified and documented before providing physical health services, according to policies and procedures, for two of four employees sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of E2’s personnel record revealed skills and knowledge documentation signed by E1 and E2. However, the skills and knowledge were not marked off as completed. 2. A review of E3’s personnel record revealed no verified skills and knowledge. 3. A review of the September 2025 personnel schedule revealed the following: -E2 worked September 2, 2025, and September 6, 2025. -E3 worked from September 1, 2025, to September 9, 2025. 4. A review of the facility’s policies and procedures revealed a policy titled “Verifying Caregiver’s Skills and Knowledge.” The policy stated, “The manager or manager’s designee should ensure that before the caregiver provides physical health or behavioral health services, his or her skills and knowledge are verified and documented.” 5. 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 a written service plan included the signature and date from the resident representative for one of two residents reviewed. The deficient practice posed a health and safety risk if the resident's representative did not acknowledge the services that were to be provided. Findings include: 1. A review of R2’s medical record revealed a service plan for directed care services dated December 20, 2024, and signed by E1. 2. During an interview, E1 reported that R2’s representative was not able to sign the service plan. E1 signed for the resident representative. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure a resident was not subjected to restraint, for one of eight total residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed bed rails on both the upper and lower half of R3's bed. The Compliance Officer observed both rails were up. 2. In an interview, E2 reported the bed rails were on R3's bed partly to hold R3's urine bag. E2 reported the rails were also up so R3 could not get out of bed when R3 became agitated. 3. In an interview, when the Compliance Officer asked if R3 could lower the rails without assistance, R3 stated, "No."

Based on record review and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for one of three sampled residents. The deficient practice posed a risk to the resident's health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. A review of R2's medical record revealed a "T.B. Test, Influenza and Pneumonia Administration" document which contained white corrective tape over the month the "T.B Skin Test" was read, effectively changing the date from "7/10/23" to "1/10/23." The document also contained white corrective tape over the "Resident's Name" with R2's name written over the different, original name. 2. In an interview, E1 confirmed white corrective tape was used on R2's TB test document. Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 13, 2023.

Based on documentation review, observation, and interview, the manager failed to ensure 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 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. During the environmental inspection of the facility, the Compliance Officer observed the front and back doors did not have controls installed but did have alerts installed. However, the alerts were turned to the "OFF" position and did not sound when the Compliance Officer opened the doors. 3. In an interview, E1 acknowledged the alerts had been turned off.

Based on documentation review, record review, observation, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of three sampled residents. The deficient practice posed a risk to the health and safety of a resident as emergency personnel would not have correct health data to make decisions regarding a resident's treatment in an emergency, and the Department was provided false or misleading information. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "DOCUMENTING MEDICATION ADMINISTRATION RECORD (MAR)/ASSISTANCE." The policy and procedure stated: "The facility shall maintain a daily Medication Administration Record (MAR) for each resident who receives assistance with self-administration of medications or medication administration. The MAR is the form on which the caregiver will document that medication has been administered to a resident. The MAR is a report that serves as a legal record of the drugs administered to a resident of the facility." 2. A review of R2's medical record revealed a current service plan which indicated R2 received medication administration. R2's medical record also contained a medication order for "Pantoprazole SOD 40 mg (milligrams) tab PO BID" dated April 24, 2024 and an order for "Pantoprazole Sodium 40 MG Tablet Delayed Release 1 tablet orally once a day" dated May 22, 2024. Further review of R2's medical record revealed a MAR dated June 2024 which indicated R2 received "Pantoprazole" twice a day on June 1-4, 2024, and once on June 5, 2024, the date of the inspection. 3. During the environmental inspection of the facility, the Compliance Officer observed R2's medication organizer contained only one tablet of "Pantoprazole" for each day, and not two as documented on the MAR. 4. In an interview, E1 reported the order recently changed from twice a day to once a day. E1 confirmed the medication was only given once a day on June 1-4, 2024, and the MAR was incorrect.

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for one of three sampled residents. The deficient practice posed a potential TB exposure risk to residents, and the Department was provided false or misleading information. Findings include: 1. A review of R2's medical record revealed a document titled "Mantoux TB Skin Test" which indicated R2 received a TB test on "1-10-2023" and had the test read on "1-12-2023." The review revealed a second TB test dated as administered on "7-10-2023," and read on "7-12-2023." However, this second TB test was faxed to the facility on February 27, 2023, several months before the test was administered, and was identical to the first test other than the month, which appeared to be changed from a "1" to a "7." The review further revealed conflicting documents using each of the dates separately, including a "T.B. Test, Influenza and Pneumonia Administration" document which contained white corrective tape over the month the "T.B Skin Test" was read, effectively changing the date from "7/10/23" to "1/10/23." R2's medical record did not contain documentation of baseline screening consisting of assessing risks of prior exposure to infectious tuberculosis and determining if R2 had signs or symptoms of TB. 2. In an interview, E1 stated the July 12, 2023, document was "Just a copy." Technical assistance was provided on this rule during the complaint and compliance inspection conducted on April 13, 2023.