Villa Hermosa Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documentation revealed a policy and procedure titled "Fall Prevention and Recovery Training" that stated "...The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery..." 2. Review of E1's personnel record revealed E1 worked as a caregiver and had a hire date of January 1, 2023. The personnel record revealed documentation of fall prevention training dated January 1, 2023. However, current documentation was not available indicating E1 completed fall prevention and fall recovery training. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of January 1, 2023. The personnel record revealed documentation of fall prevention training dated January 1, 2023. However, current documentation was not available indicating E2 completed fall prevention and fall recovery training. 4. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of January 29, 2024. The personnel record did not include documentation that showed E4 completed fall prevention and fall recovery training. 5. Review of E5's personnel record revealed E5 worked as a manager and had a hire date of March 18, 2021. The personnel record revealed documentation of fall prevention training dated January 20, 2022. However, current documentation was not available indicating E5 completed fall prevention and fall recovery training. 6. In an interview, E1 and E2 acknowledged documentation was not available that showed E1, E2, E4, and E5 had completed initial training and continued competency training for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R2's medical record revealed R2 refused the flu and pneumonia vaccinations July 15, 2022. However, current documentation was not available that showed the flu and pneumonia vaccinations were offered or received. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R2's medical record did not include current documentation that showed the flu and pneumonia vaccinations were offered or received.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated February 1, 2024. This service plan stated "Patient is bedbound". 2. Review of R2's medical record revealed a written determination from R2's medical practitioner signed and dated October 25, 2022. However, documentation was not available that stated R2's needs could be met by the facility and R2's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E1 reported R2 was unable to ambulate even with assistance since at least January 2023 and E1 and E2 acknowledged R2's medical practitioner did not provide a written determination at least once every six months.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated December 18, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated February 5, 2024. These medication orders stated the following: "HumaLog KwikPen Subcutaneous Solution Pen-Injector 100 Unit/ml sig: inject 15 units before lunch and dinner BID hold if BS is <100" "HumaLog KwikPen Subcutaneous Solution Pen-Injector 100 Unit/ml sig: inject 11 units QAM subcutaneously" 3. Review of R1's medical record revealed a February 2024 medication administration record (MAR). This MAR stated the following: "Insulin Lispro Pen 100unit/ml Inject 15 units SQ BID before lunch & dinner (hold if BS <100)" and indicated the insulin was held every day at 11am and 4pm February 1st - present. "Insulin Lispro Pen 100unit/ml Inject 11 units SQ QD (hold if BS <100)" and indicated the insulin was administered at 8am February 1st - 2nd and held February 3rd - present. 4. Review of R1's medical record revealed R1's blood sugar (BS) was only recorded at breakfast February 1st - present. 5. During an observation of R1's medications, Lispro (Humalog) was observed. 6. In an interview, E3 reported the medications were administered per the February MAR. E1 and E2 acknowledged R1's medications were not administered in compliance with the available medication order.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R1's medical record revealed a current written service plan dated December 18, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed a signed medication order dated February 5, 2024. This medication order stated "Calmoseptine Oint 0.44-20.6% sig: Apply topically to the groin after each diaper change. Keep clean and dry". 3. Review of R1's medical record revealed a February 2024 medication administration record (MAR). This MAR stated "Calmoseptine ointment Apply topically to groin @ diaper changes PRN" and did not indicate this medication was administered February 1st - present. 4. During an observation of R1's medications, Calmoseptine was observed. 5. In an interview, E3 reported Calmoseptine was administered per the medication order. E1 and E2 acknowledged R1's medical record did not include documentation the medication was administered.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Disaster plan, Relocation, Records, Medication, Food and Water." However, the most recent available documentation showed the disaster plan was last reviewed June 25, 2022. 2. In an interview, E1 and E2 acknowledged the facility's disaster plan was not reviewed at least once every 12 months.