Villa De Hope

Based on record review, documentation review and interview, the health care institution failed to implement a training program regarding fall prevention and fall recovery training to include initial training and continued competency. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. A review of E3's and E4's personnel record revealed documentation of initial training in fall prevention and fall recovery was unavailable for review. 2. A review of facility documentation revealed a document titled "Sign in roster for fall prevention and recovery," dated June 7, 2024. The document identified E2 as receiving continued competency training on the topic. However, evidence of documentation indicating E4 received continued competency training in fall prevention and fall recovery was unavailable for review. Based on E3's date of hire, continued competency training was not required. Further review of facility documentation revealed an undated fall prevention and recovery program, however the program did not include a method to ensure continued competency in fall prevention and fall recovery. 3. In an interview E1 agreed E3's and E4's personnel record did not include evidence of initial training or continued competency in fall prevention and fall recovery. E1 acknowledged the fall prevention and fall recovery program did not include continued competency training as required.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. Findings include: 1. A review of Department documentation revealed the facility had E1 still listed as the manager of this facility as of March 10, 2022. 2. During a tour of the facility, the compliance officer observed a copy of E5's license hanging in the facility's office. Research conducted through the Arizona Nursing Care Institution Administrators and Assisted Living Facility Managers portal, https://aznciab.portalus.thentiacloud.net/webs/portal/register/#/, revealed E5's license to be valid and current. 3. In an interview, E1 acknowledged the Department had not been notified of a change in manager at the facility.

Based on record review, documentation review, and interview, the manager failed to ensure a manager, a caregiver, and an assistant caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three employees sampled who were expected to have more than eight hours per week of direct interaction with residents. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E3's (hire date September 10, 2024) personnel record revealed a medical record titled "Final Radiology Report," which documented an "Examination: Chest, Single View, Frontal," screening for "respiratory tuberculosis." The record reflected a "negative" impression and was signed by a medical provider on December 14, 2023. However, of evidence of a negative two step TB skin test or negative blood test within twelve months prior to E3's direct interaction with residents was unavailable for review. Furthermore, evidence of a signs and symptoms assessment or risk of prior exposure to TB assessment, signed by an occupational health reviewer was unavailable for review. 2. In an interview, E1 agreed E3's personnel record did not contain current documentation of evidence of freedom from infectious TB.

Based on documentation review, record review, observation and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed in-service education required by policies and procedures, for two of three personnel members sampled. Findings include: 1. A review of facility policy and procedures (reviewed June 28, 2023) revealed a policy titled, "Upon Employment." The policy stated "Employees shall complete at least two hours of continuing education each year on a health related topic of their choice, but cannot include CPR or first aid training." 2. A review of the facility staffing schedule for September 2024 revealed E4 worked as a caregiver on September 2-5, 9-13 and 16-19, 2024, and E2 worked as a caregiver on September 2-6, 9-13 and 16-20, 2024. 2. A review of E2's personnel record revealed E2 was hired as a caregiver on September 14, 1998. However, evidence of documentation of E2's completed continuing education in 2023 was not available for review. 3. A review of E4's personnel record revealed E4 was hired as a caregiver on July 15, 2021. However, evidence of documentation of E4's completed continuing education for 2023 was not available for review. 4. During a tour of the facility, the Compliance Officer observed E2 to be working and providing assisted living services to residents. 5. In an interview, E1 agreed E2 and E4 had not received continuing education as required by facility policy.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does 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 general or specific whereabouts of a resident. Findings include: 1. A review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E2, the compliance officer observed a set of French doors in a resident's room which lead out to the backyard. The outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The French doors were equipped with a thumb turn dead bolt lock and a thumbprint locking handle. However, the doors were not equipped with a device intended to alert employees to the egress of a resident to the outside area. 3. In an interview, E1 acknowledged the French doors did not control or alert employees of the egress of a resident.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered in compliance with a medication order for one of three residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan which indicated R2 received personal care, and medication administration services. The medical record contained a doctor's order, dated July 9, 2024, directing R2 take the following medications, within parameters identified: "Midodrine HCL Oral Tablet...Give 5 mg by mouth three times a day for hypotension hold for sbp greater than 120;" "Carvedilol Oral Tablet...Give 12.5 mg by mouth every 12 hours for HTN hold for SBP < 110 pulse <60;" and "Digoxin Oral Tablet...give 125 mcg by mouth one time a day every other day for Cardiac arrythmia." 2. A review of R2's Medication Administration Record (MAR) for September 2024 revealed a section documenting the administration of "Midodrine HCI 5mg tab one tab oral three times a day," "Carvedilol 12.5mg tab one tab oral two times a day (HTP), and "Digoxin 125mcg tab one tab oral one time a day every other day." Entries reflected Midodrine was administered at "7am," 12pm" and "7pm," from September 1 through September 19, 2024, with the exception of September 7 and 8, 2024, when R2 was out of the facility. Entries also reflected Carvedilol was administered at "7am" and "7pm" from September 1 through September 19, 2024, with the exception of September 7 and 8, 2024, when R2 was out of the facility. In addition, entries indicated Digoxin was not administered on any day between September 1 and September 19, 2024. 3. Further review of R2's medical record revealed a document titled "Blood Pressure" used to document R2's blood pressure at "breakfast," "lunch," and "dinner" time of the day in September. Entries on the dates and times below indicated systolic blood pressures outside parameters for Midodrine to be administered: "-September 1, breakfast, 162/96; -September 2, breakfast, 162/96; -September 3, lunch, 130/94; -September 3, dinner 136/82; -September 4, breakfast, 124/77; -September 11, breakfast, 127/75; -September 12, lunch, 124/77; -September 12, dinner, 130/94 -September 13, lunch 152/96; and -September 18, dinner 127/80" Evidence of documentation R2's blood pressure was obtained and documented prior to administration of Carvedilol at 7 a.m. or 7 p.m. was unavailable for review. However, entries on the dates and times below indicated systolic blood pressures outside parameters for Carvedilol to be administered: "-September 3, breakfast, 108/50;" -September 5, breakfast, 109/70; -September 9, breakfast 96/74; -September 10, breakfast 103/79; -September 13, breakfast, 108/50; -September 13, dinner, 109/59; -September 15, breakfast, 9/4/60" presumed to read 94/60; -September 16, breakfast, 77/53 -September 17, breakfast, 89/51; -September 18, breakfast, 67/52; -September 19, breakfast, 82/79; -September 19, dinner, 105/72; and -September 20,

Based on observation and interview, the manager failed to ensure that poisonous or toxic materials were stored in a locked area, separate from medications and inaccessible to residents. Findings include: 1. During a tour of the facility, the compliance officer observed no fewer than three ambulatory residents, and the following: In an unlocked storage room in the back yard, two plastic buckets marked "Clorox Pool & Spa Chlorinating tablets." The label affixed to the buckets read, "HAZARDOUS TO HUMANS AND DOMESTIC ANIMALS: DANGER: Corrosive: Causes irreversible eye damage." 2. In an interview, E1 acknowledged the poisonous and toxic materials were not kept in a locked area, inaccessible to residents.

Based on observation and interview, the manager failed to ensure a swimming pool enclosure's gate was locked when the swimming pool was not in use. Findings include: 1. During an environmental tour, the compliance officer observed ambulatory residents on the backyard patio at the time of the inspection, and observed the swimming pool was not in use. The swimming pool was surrounded by an enclosure, separating the pool from the patio and remainder of the back yard. The compliance officer observed the swimming pool enclosure's gate was equipped with a latch which could be secured with a padlock, and a padlock was hanging from the enclosure, next to the gate. The gate was also equipped with a deadbolt lock which required a key. However, the deadbolt was not engaged and the compliance officer was able to open the gate with little effort. The enclosure was equipped with a second gate which granted egress to the main driveway of the facility. The gate was also equipped with a deadbolt which required a key. However, the deadbolt was not engaged and the compliance officer was able to open the gate with little effort. 2. In an interview, E1 acknowledged the swimming pool was not locked when the swimming pool was not in use.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by the assisted living facility, there was a documented residency agreement with the assisted living facility which included the manager's signature and date signed, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed a documented residency agreement, signed by the resident. However, the residency agreement had not been signed or dated by the manager. 2. In an interview, E1 acknowledged the manager had not signed and dated the residency agreement provided for R1.

Based on observation, record review, and interview, the manager failed to ensure that medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a prescription tube of "Clobetasol" ointment on top of a dresser in R1's bedroom. 2. A review of R1's medical record revealed a service plan, dated April 7, 2023, for personal care services including medication administration. 3. During an environmental inspection of the facility, the Compliance Officer observed the door to the office was open and the keys to the door had been left in the lock. The Compliance Officer observed all four staff present in the kitchen area at the beginning of the inspection and during the facility tour, the Compliance Officer observed E1 left the office unlocked while accompanying the Compliance Officer on the tour. The compliance Officer observed the following medications in unlocked cabinets in the office: - "Rugby Chest Congestion Relief DM syrup"; - "Method Guaifenesin and Dextromethorphan Hydrobromide Syrup"; - "Equate Oxymatazoline HCI Nasal Spray"; - "Acarbixin, Amoxicilina / Acido Clavulanico 500 mg Tablets"; - "Senna SUP 6.8/5 ML syrup"; and - "Equate Pain Reliever Acetaminophen 500 mg capsules." 4. In an interview, E1 acknowledged medication was not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were maintained in a locked area separate from food preparation and storage areas and were inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the laundry room door had a lock, however, the door had been left unlocked. The Compliance Officer observed no staff were present inside the laundry room during the inspection. Inside the laundry room, the Compliance Officer observed a tote containing spray bottles of "Clorox Multi Purpose Cleaner," and, "Great Value Glass Cleaner." Inside a cabinet, the Compliance Officer observed a gallon bottle of bleach. 2. In an interview, E1 acknowledged poisonous or toxic materials were not maintained in a locked area inaccessible to residents.