West Lane Home

Based on observation and interview, the manager failed to ensure that a resident was not subjected to restraint. The deficient practice posed a risk of injury and violated a resident's rights. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a bedrail that covered the top half of R4's bed. R4 was sitting at the edge of the bed, leaning against the rail. 2. In an interview, R4 revealed that it is hard for R4 to get out of bed when the bed rail is up. R4 also revealed that R4 feels confined to the bed when the bed rail is up. R4 reported that R4 was unable to lower the bed rail on their own. 3. In an interview, E1 reported that R4 was intermittently confused and needed assistance getting out of bed. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided

Based on observation, documentation review, and interview, the administrator failed to maintain a health care institution within the licensed capacity of five residents. The deficient practice posed a risk if the Department was unable to assess and approve an increased occupancy. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed six individuals living on the premises. 2. A review of Department documentation revealed the following documents: -An issued license from the Department for a total capacity of 5; -A completed building permit from the City of Phoenix with the description "A Group Home for 1-5 residents..."; and -A fire permit from the City of Phoenix with the description "General fire inspection for assisted living facility-5 Beds." 3. In an interview, E1 reported five individuals were residents, and one individual was independent living. 4. In an interview, E2 acknowledged the health care institution was not maintained within the licensed capacity of five residents.

Based on observation and interview, the manager failed to ensure meals and snacks provided by the assisted living facility were served according to posted menus. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a document titled "Facility March Menu". The document showed breakfast, lunch, dinner, and snacks scheduled to be provided to the residents for the dates of March 24, 2024 through March 30, 2024. The Compliance Officer observed on March 28, 2024, breakfast was listed as "Bagels w/ sausage links." 2. In an interview, E1 stated the residents had "pancakes and eggs" for breakfast on the date of the inspection. E1 reported breakfast was served between 7:00 AM and 8:00 AM, and E1 reported E1 had not written the subsitution on the menu before the Compliance Officer arrived at the facility. 3. In an interview, E2 acknowledged breakfast provided by the assisted living facility on the date of the inspection was not served according to the posted menu.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents. The deficient practice posed a risk of not meeting a resident's hygeine needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer measured the hot water temperature at the kitchen sink and the bathroom sink. The temperatures recorded were 102.3\'ba F and 101.7\'ba F, respectively. 2. In an interview, E1 reported from March 4, 2024 to March 12, 2024, the water heater at the facility was broken, and the facility was without hot water during that period. 3. In an interview, E2 acknowledged hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents from March 4, 2024 to March 12, 2024.

Based on observation and interview, the manager failed to ensure the supply of hot and cold water was sufficient to meet the personal hygiene needs of residents and the cleaning and sanitation requirements in this Article. The deficient practice posed a risk of not meeting a resident's hygeine needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer measured the hot water temperature at the kitchen sink and the bathroom sink. The temperatures recorded were 102.3\'ba F and 101.7\'ba F, respectively. 2. In an interview, E1 reported from March 4, 2024 to March 12, 2024, the water heater at the facility was broken, and the facility was without hot water during that period. 3. In an interview, E2 acknowledged hot water temperatures were not maintained between 95\'ba F and 120\'ba F in areas of the assisted living facility used by residents from March 4, 2024 to March 12, 2024.

Based on documentation review and interview, the manager failed to ensure documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, was maintained for at least 12 months after the last date on the documentation. Findings include: 1. A review of facility documentation revealed staffing schedules dated for April, June, July, and August, 2023. The Compliance Officer requested to review a staffing schedule for May 2023. However, no documentation of the caregivers and assistant caregivers working each day, including the hours worked by each, for May 2023 was available for review. 2. In an interview, E1 reported E1 believed the same caregivers and assistant caregivers worked the same hours each day in May 2023 as they did in June 2023. E1 acknowledged documentation of the caregivers working each day, including the hours worked by each, in May 2023 was not maintained.

Based on documentation review and interview, the manager failed to ensure as part of the policies and procedures required in Arizona Administrative Code (A.A.C.) R9-10-803(C)(1)(h), a plan was documented to ensure the manager or a caregiver was available as 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. Findings include: 1. A review of facility policies and procedures revealed a policy titled "Staffing Documentation And Recordkeeping" as required in A.A.C. R9-10-803(C)(1)(h). However, the policy did not include a plan to ensure the manager or a caregiver was available as 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. 2. In a phone interview, E3 reported there was always at least one caregiver living on site, and one backup caregiver listed on the schedule. However, E3 acknowledged the facility did not have a documented plan to ensure the manager or a caregiver was available as 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 3. In an interview, E1 acknowledged the facility did not have a documented plan to ensure the manager or a caregiver was available as 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

Based on record review and interview, the manager failed to ensure a resident's medical record contained the date of termination of residency, for one of one former resident sampled. Findings include: 1. A review of R4's medical record revealed documentation of the date of R4's termination of residency was not available for review. R4's medical record contained no information regarding R4's discharge from the facility. 2. In an interview, E1 acknowledged R4's medical record did not include R4's date of termination of residency.

Based on observation, record review, and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication administered to the resident or for which the resident received assistance in the self-administration of medication, for one of four residents sampled. Findings include: 1. The Compliance Officer observed a medication bottle containing "Venlafaxine HCL 75MG (milligrams) 24HR SA Cap" in R1's medication basket. The label on the bottle stated, "Take one capsule by mouth every day for 14 days, then take two capsules for mood." 2. A review of R1's medical record revealed a medication administration record (MAR) for August 2023. R1's August 2023 MAR indicated R1 received "Venlafaxine HCL 150mg 1 cap po QD'' at 8:00 AM on August 2-9, 2023. However, further review of R1's medical record revealed no medication order for "Venlafaxine HCL" was available for review. 3. In an interview, E1 reported the facility was working with R1's doctor to get a signed medication order for "Venlafaxine". E1 acknowledged the manager failed to ensure R1's medical record contained a medication order from a medical practitioner for each medication R1 was administered.

Based on record review, documentation review, and interview, the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for one of four residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan which indicated R2 received medication administration. R2's medical record also revealed a medication order dated July 25, 2023 for "Bactrim DS Oral Tablet 800-160 MG (milligrams)...1 tab po BID for 10 days bladder infection...Start Date: 7/25/2023." 2. Further review of R2's medical record revealed medication administration records (MARs) dated for July and August 2023. The MARs revealed "Bactrim" was documented as administered to R2 on July 26, 2023 at 5:00 PM, and July 27-31, 2023 at 8:00 AM and 5:00 PM. However, no documentation indicating the medication was administered to R2 as ordered in August 2023 was available for review. 3. In an interview, E1 reported R2 had received "Bactrim" twice a day for ten days as ordered. E1 acknowledged administration of "Bactrim" in August 2023 was not documented in R2's medical record.