Wellspring Alh in Chandler

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated June 20, 2024. This service plan stated the following services were needed: "-Incontinence Checks: Every 2 hours as tolerated; -Change garments and Cleanse Skin if Soiled; and -Apply Skin Barrier " However, documentation was not available indicating these services were provided. 2. During an interview, E1 acknowledged R1's medical record did not include documentation of the above listed services.

Based on record review and interview, the manager failed to ensure a service plan included cognitive stimulation and activities to maximize functioning, for one of one resident reviewed receiving directed care services. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care service dated June 20, 2024. This service plan revealed no documentation of cognitive stimulation and activities to maximize functioning. 2. During an interview, E1 acknowledged R1's service plan did not include cognitive stimulation and activities to maximize functioning.

Based on record review and interview, the manager failed to ensure when a resident had an incident resulting in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident resulting in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a document titled "Incident Report" dated August 21, 2024. This document indicated the time of incident was 10:01pm and stated "[E1] was in the bathroom showering and getting ready for bed. When [E1] was done [E1] went out and heard the alarm so [E1] rushed to [R1] and saw [R1] by the door in [R1's] room scooting towards [R1's] bed [...] When [R1] was in bed, [R1] said [R1] hit [R1's] head [...] " and reported 911 was called and Emergency Medical Service provided treatment. However, the documentation did not include any action taken to prevent the incident from occurring in the future. 2. During an interview, E1 acknowledged R1's medical record did not include documentation of the any action taken to prevent the incident from occurring in the future.

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. 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". This policy stated "Training staff regarding Fall Prevention and Fall Recovery is done once a year." 2. Review of E2's personnel record revealed a certificate for Fall Prevention training from 2022. However, the personnel record did not include documentation that showed E2 completed fall prevention and fall recovery training in 2023. 3. Review of E1's personnel record revealed no documentation showing that E1 had completed Fall Prevention and Fall Recovery training. 4. In an interview, E1 acknowledged E1's and E2's personnel record did not contain documentation that showed the health care institution had administered a training program for all staff regarding fall prevention and fall recovery.

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: A.R.S. \'a7 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 1. The Compliance Officer observed R1's medical record was sitting on the dining room table at the start of the inspection, before the Compliance Officer requested any documents or records. 2. During a tour of the facility with E3, the Compliance Officer observed medical records for all residents were stored on a counter top in the kitchen. 3. During an interview, E1 reported not having space to store the records securely. E1 acknowledged that resident's medical records were not protected from loss, damage, or unauthorized use.

Based on documentation review, 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, and 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 Department documentation revealed the facility was authorized to provide directed care services. 2. During the facility tour with E3, the Compliance Officer observed the door leading out to the backyard. The outside area, in the backyard, allowed residents to be at least 30 feet away from the facility. The door leading out to the backyard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device did not work. 3. In an interview, E1 reported the alarm does work, but the battery was dead. E1 acknowledged there was not a means of exiting the facility that controlled or alerted employee of the egress of the resident.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings include: 1. During a tour of the facility with E3, the Compliance Officer observed an unstable ramp at the door to the back yard. 2. In an interview, E1 acknowledged the unstable ramp created a fall hazard. E1 acknowledged the premises and equipment used at the assisted living facility were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Based on observation and interview, the manager failed to ensure garbage and refuse were stored in covered containers lined with plastic bags. Findings include: 1. During a tour of the facility with E3, the Compliance Officer observed uncovered containers storing garbage and refuse in the kitchen and in resident bedrooms. 2. In an interview, E1 acknowledged garbage and refuse were not stored in covered containers.

Based on observation and interview, the manager failed to ensure combustible or flammable liquids and hazardous materials stored by the assisted living facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During a tour of the facility with E3, the Compliance Officer observed the following in an unlocked drawer in the kitchen: -"Bic Wite-Out" which stated "Danger: Extremely Flammable"; -"Bic correction fluid" which stated "Danger: Extremely Flammable"; -Nail polish, "Danger: Flammable". 2. In an interview, E1 acknowledged combustible or flammable liquids stored by the assisted living facility were not stored in a locked area inaccessible to residents.