West Valley Helping Hands

Based on document review, observation, record review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I), which required immediate notification to the Department in writing, identifying the name and qualifications of the new manager when there was a change in the manager. Findings include: 1. A review of Department records revealed E4 was listed as the manager. 2. During the environmental inspection, the Compliance Officer observed E1's manager's certificate posted near the front door of the facility. 3. In an interview, E2 and E3 reported E4 was no longer the manager and E1 was the new manager. 4. A review of E1's personnel record revealed a hire date of April 10, 2024. 5. In a telephonic interview, E1 reported notifying the Department, however, E1 provided incorrect information, including an inaccurate Facility Name and Address, when providing the notification to the Department. E1 acknowledged the Department was not notified in writing of the change in manager.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility 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 records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the front door leading to the front yard, which lead to the street. The door leading out to the front yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was not functioning. 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are triggered will be investigated immediately by the caregiver on duty." 4. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a 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 that provided access to an outside area from which a resident may exit to a location at least 30 feet away from the facility 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 records revealed the facility was licensed to provide directed care services. 2. During the environmental tour, the Compliance Officer observed the back yard did not allow residents to be at least 30 feet away from the facility. The door leading out to the back yard had a device that was intended to alert employees to the egress of a resident to the outside area. However, the device was not functioning. 3. A review of facility policies and procedures revealed a policy titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and or windows, the caregiver will check them daily for operation and security. Alarms that are triggered will be investigated immediately by the caregiver on duty." 4. In an interview, E2 and E3 acknowledged the facility did not have a means of exiting to an outside area that allowed a resident to be at least 30 feet away from the facility and controlled or alerted employees to the egress of a resident from the facility.

Based on record review and interview, the manager failed to ensure a written service plan was available, for one of four residents reviewed. The deficient practice posed a health and safety risk if the caregivers did not know the services the resident needed to receive. Findings include: 1. Review of R3's medical record revealed no documentation of a written service plan. Based on R3's date of acceptance, a service plan was required. 2. In an interview, E1 acknowledged R3's personnel record did not include a written service plan and reported R3's service plan was given to R3 upon R3's discharge.

Based on record review, observation, and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for one of two residents reviewed. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a current written service plan dated June 8, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of a signed medication order or a verbal medication order for Cyclobenzaprine. 3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Cyclobenzaprine 5mg 1 PO TID" and indicated one tab was administered at 8am, 1pm, and 8pm August 1st - present. 4. During an observation of R2's medications, Cyclobenzaprine 5mg was observed and one tab was observed prefilled in the "Morn," "Noon," and "Bed" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medical record did not contain a medication order from a medical practitioner for a medication that was administered.

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 November 1, 2021. However, current documentation was not available showing the flu and pneumonia vaccinations were offered or received. Based on R2's acceptance date, this documentation was required. 3. In an interview, E1 acknowledged R2's medical record did not include current documentation showing the flu and pneumonia vaccinations were offered or received.

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 R2's medical record revealed a current written service plan dated June 8, 2023. This service plan indicated R2 received medication administration. 2. Review of R2's medical record revealed no documentation of a signed medication order or a verbal medication order for Cyclobenzaprine. 3. Review of R2's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Cyclobenzaprine 5mg 1 PO TID" and indicated one tab was administered at 8am, 1pm, and 8pm August 1st - present. 4. During an observation of R2's medications, Cyclobenzaprine 5mg was observed and one tab was observed prefilled in the "Morn," "Noon," and "Bed" slot of R2's medication organizer. 5. In an interview, E1 reported the medication was administered per the medication organizer and acknowledged R2's medication was not administered in compliance with an available medication order. 6. This is a repeat deficiency from the compliance inspection conducted December 5, 2022.