White Violet Adult Care Home III

Based on documentation review, record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication Services”. The policy stated, “The trained caregiver will initial in the resident’s MAR, including the date and time the medication was given to the resident and the medications that were taken.” 2. A review of R2's medical record revealed a current medication order for Risperidone 1 milligram (mg), 1 tablet by mouth (po), daily (qd). 3. A review of R2's medication administration record (MAR) for March 2026 revealed no documentation of Risperidone 1 mg administered from March 1, 2026 to March 13, 2026. 4. While on-site for the compliance inspection, the Compliance Officer observed one prescription pill bottle of Risperidone 1 mg stored for administration to R2. 5. While on-site for the compliance inspection, the Compliance Officer observed one tablet of Risperidone in R2’s pill organizer. 6. In an interview, E1 reported the medication was administered every day, but E1 forgot to add it to the MAR. 7. In an exit interview, the findings were discussed with E1, and no additional information was provided. 8. This is a repeat deficiency from the abbreviated inspection conducted on December 7, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure accurate 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. The deficient practice posed a risk if there was no documentation to identify whether qualified staff were present each day to ensure the health and safety of residents. Findings include: 1. The Compliance Officer arrived at AL12634 at approximately 2:10 PM and observed E1 working alone at the facility, with three residents present. The Compliance Officer observed E2 arrived at the facility at approximately 2:45 PM. 2. In an interview, E1 reported to be employed as a caregiver at the facility. 3. A review of the posted schedules for September 2023 through December 2023 revealed no documentation of the hours worked by E1. The schedule indicated E2 was scheduled to work from 7:00 AM to 7:30 PM on December 7, 2023, and E1 was not scheduled to work. 4. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Staffing and Record Keeping." The P&P stated, "Shift coverage and work schedule...Is maintained: i. Throughout the employee's or volunteer's period of providing services in or for the assisted living facility." 5. In an interview, the Compliance Officer requested to review E1's personnel record. However, E2 stated, "[E1] doesn't have a personnel record." E2 reported E1 was a "helper" [assistant caregiver] and stated, "I had an emergency and had to leave [E1] here." E2 acknowledged documentation was not maintained after the last date on the documentation of the assistant caregivers working each day, including the hours worked by each assistant caregiver.

Based on observation, documentation review, record review, and interview, the manager failed to maintain a personnel record for each employee which included the items required by this rule, for one of two personnel sampled. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer arrived at AL12634 at approximately 2:10 PM and observed E1 working alone at the facility, with three residents present. The Compliance Officer observed E2 arrived at the facility at approximately 2:45 PM. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Staffing and Record Keeping." The P&P stated, "The facility manager shall ensure that a personnel record for each employee is maintained [and] Includes...The individual's name, date of birth, and contact telephone number...The starting date of employment or volunteer service and, if applicable, the ending date...Documentation of...The individual's qualifications, including skills and knowledge applicable to the individual's job duties...The individual's education and past experience which are applicable to the individual's job duties...The individual's completed orientation and in-service education required by policies and procedures...Documentation of Tuberculosis screening and risk assessment as per "Tuberculosis (TB) Control - Tuberculosis Screening" policy and procedure...Cardiopulmonary resuscitation training...First aid training; and...Documentation of compliance with the fingerprinting requirements in A.R.S. \'a7 36-411." 3. A review of facility personnel records revealed no personnel record for E1. 4. In an interview, the Compliance Officer requested to review E1's personnel record. However, E2 stated, "[E1] doesn't have a personnel record. I didn't make one for [E1]."

Based on record review, documentation review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy and as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of three residents sampled. The deficient practice posed a potential TB infection risk to residents. Findings include: 1. A review of R1's and R3's medical records revealed a completed TB screening and risk assessment. However, R1's and R3's medical records revealed no documentation of freedom of infectious TB. Based on R1's and R3's dates of acceptance, this documentation was required. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Resident Acceptance, Rights, Termination." The P&P stated, "Before or within seven calendar days after the resident's date of occupancy into our facility the facility manager shall ensure that the resident provides evidence of freedom from infectious tuberculosis. Documentation of Tuberculosis screening and risk assessment." 3. In an interview, E2 reported facility staff were not done completing R1's and R3's medical records. E2 acknowledged R1's and R3's medical records did not include evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's dates of occupancy and as specified in A.A.C. R9-10-113.

Based on record review, documentation review, and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation that was dated within 90 days before the individual was accepted by an assisted living facility, and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant that included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for two of three resident records reviewed. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's and R2's medical records revealed no documentation dated within 90 calendar days before R1 and R2 were accepted by the assisted living facility which indicated whether R1 and R2 required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant. Based on R1's and R2's dates of acceptance, this documentation was required. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Resident Acceptance, Rights, Termination." The P&P stated, "Before or at the time of acceptance of an individual expected to receive assisted living services, the individual submits documentation that is dated within 90 calendar days before the individual is accepted stating if the individual needs continuous medical services, continuous or intermittent nursing services, or restrains that is dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant." 3. In an interview, E2 reported facility staff were not done completing R1's and R2's medical records. E2 acknowledged R1's and R2's medical records did not include the required documentation dated within 90 calendar days before R1 and R2 were accepted by the assisted living facility.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a resident who required a restraint, including the use of a bedrail, was not retained, for two of three sampled residents. The deficient practice posed a risk if a resident required a higher level of service than the facility was authorized to provide. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed R1's bedroom, where R1 was lying in bed. R1's bed had a half-bedrail in the up position. 2. During the environmental inspection of the facility, the Compliance Officer observed R3's bed contained a full bedrail with one half up and the other half down. 3. A review of facility policies and procedures (P&P) revealed a P&P titled, "Resident Acceptance, Rights, Termination." The P&P stated, "A manager shall not accept or retain an individual [who] requires restraints, including the use of bedrails." 4. In an interview, E2 reported R1 was bedbound and required a bedrail to prevent R1 from falling out of bed, and R3 used bedrails to prevent R3 from falling out of bed.

Based on record review, documentation 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 requirements in Arizona Administrative Code (A.A.C.) R9-10-807(D)(1)-(10), for two of three sampled residents. The deficient practice posed a risk if the resident was not informed of the terms of residency. Findings include: 1. A review of R1's and R2's medical records revealed a documented residency agreement was not available for review. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Resident Acceptance, Rights, Termination." The P&P stated, "Before or at the time of an individual's acceptance by our assisted living facility, a manager shall provide the individual with the residency agreement with the assisted living facility." 3. In an interview, E2 reported facility staff were not done completing R1's and R2's medical records. E2 acknowledged R1's and R2's medical records did not include completed and signed residency agreements.

Based on record review, documentation review, and interview, the manager failed to ensure a resident's written service plan was completed no later than 14 calendar days after the resident's date of acceptance, for two of three residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R1's and R3's medical records revealed a service plan was not available for review. Based on R1's and R3's dates of acceptance, this documentation was required. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Scope of Services Provision of Assisted Living Services." The P&P stated, "The facility manager or designee will conduct an assessment to assist in determining eligibility, developing an individualized Service Plan, arrange for services, maintain contact with participants, and monitor service delivery on a monthly basis." 3. In an interview, E2 reported facility staff were not done completing R1's and R3's medical records. E2 acknowledged R1's and R3's medical records did not include a current written service plan.

Based on documentation review, record review, observation, and interview the manager failed to ensure medication administered to a resident was documented in the resident's medical record, for three of three residents sampled. The deficient practice posed a risk if a resident experienced a change in condition due to improper medication administration. Findings include: 1. In an interview, E2 reported E2 provided medication administration services to residents. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Part III- Medication Administration, Records and Monitoring." The P&P stated, "Medication administration records will be filled by the authorized personnel that are doing medication administration and/or assisting in self-medication administration only after observing the resident taking the medication. The time and date will be recorded as well as the initials of the person that administered the medication or assisted in the self-administration of medication. These records should be maintained in the facility for at least 6 years." 2. A review of R1's medical record revealed a hospice medication list for the following medications: -"Citalopram 20 MG (milligrams) Tablet, 1 time a day"; -"Gabapentin 100 MG Capsule, 3 times a day"; -"Lisinopril 20 MG Tablet, 1 time a day"; -"Simvastatin 10 MG Tablet, 1 time a day"; and -"Verapamil ER (SR) 240 MG Tablet, 1 time a day." 3. Further review of R1's medical record revealed a medication administration record (MAR) for November 2023. The MAR revealed R1 was administered the following medications: -"Citalopram" at 8:00 AM on November 19-21, 2023; -"Gabapentin" at 8:00 AM and 2:00 PM on November 19-21, 2023, and at 8:00 PM on November 18-21, 2023; -"Lisinopril" at 8:00 AM on November 19-21, 2023; and -"Verapamil ER (SR)" at 8:00 AM on November 19-21, 2023. However, the MAR revealed no documentation to indicate R1 was administered "Simvastatin" at any time or the aforementioned medications from November 22, 2023 to present. 4. The Compliance Officer observed R1's medication box did not include "Simvastatin 10 MG Tablets." 5. A review of R2's medical record revealed no documentation of a medication list or signed orders. However, R1's medical record revealed a MAR from Salibas Pharmacy for December 2023. The MAR included the following medications: -"Acetaminophen 500 MG Tablet, take 2 tablets by mouth twice a day"; -"Alprazolam 0.5 MG Tablet, take 1 tablet by mouth once daily at 5 PM"; -"Carbidopa-Levodopa 25-250, take 1 tablet by mouth three times daily"; -"Docusate 100 MG Softgel, take 1 capsule by mouth every other day"; -"Furosemide 40 MG Tablet, take 1 tablet by mouth once daily"; -"Klor-Con 10 MEQ (milliequivalent units) Tablet, take 1 tablet by mouth once daily with food"; -"Lactulose 10 GM (grams)/15 ML (milliliters) Sol, take 15 ML by mouth once daily for elevated ammonia"; -"Paroxetine HCL 40 MG Tablet, take 1 tablet by mouth once daily"; -"Pramipexole 0.5 MG Tablet,

Based on documentation review, observation, and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a health and safety risk to residents who were not prescribed the accessible medication. Findings include: 1. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Part II- Receiving, Storing, Inventorying, Tracking, Dispensing Medications Including Opioids and Narcotics." The P&P stated, "Medication stored by the facility will be locked in the medication storage area." 2. During the environmental inspection of the facility, the Compliance Officer observed a kitchen cabinet without a lock. The following medications were stored with food products: -"Lactulose Solution USP 10 g (grams)/15 mL (milliliters)"; and -"Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative". 3. During the environmental inspection of the facility, the Compliance Officer observed a bottle of "Zyrtec" on the nightstand in bedroom four. Both doors leading into bedroom four were unlocked. 4. In an interview, E2 reported E1 was using bedroom four. 5. During the environmental inspection of the facility, the Compliance Officer observed the following medications on R3's nightstand in bedroom two: -A box of "Fluticason Propionate/Salmeterol DISKUS Inhalation Powder 250 mcg (micrograms)/50 mcg"; and -A tube of "Calmoseptine Ointment". 6. During the environmental inspection of the facility, the Compliance Officer observed a hallway closet with a lock. However, the lock was in the open position at the time of the observation. The closet contained a tube of "Calmoseptine Ointment" stored with personal care items such as soap and hair conditioner. 7. In an interview, E2 acknowledged medications stored by the facility were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

Based on observation, documentation review, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety of residents with access to the materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed the laundry room door was ajar with the key stored in the door knob making it accessible to residents. The laundry room contained the following poisonous or toxic materials: -Ten containers of "Tide pods"; -Three bottles of "Clorox" cleaner; -Three spray cans of "Pledge"; -Two bottles of "Clorox Toilet Bowl Cleaner"; -One spray can of "Lysol Disinfectant spray"; -One bag of "Cascade Platinum dishwasher packs"; -One bottle of "Goo Gone"; -One bottle of window cleaner; -One bottle of floor cleaner; and -One bottle of stove top cleaner. 2. A review of facility policies and procedures (P&Ps) revealed a P&P titled, "Environmental and Physical Plant Safety." The P&P stated, "Poisonous and toxic materials will be...stored in a locked area...inaccessible to residents." 3. In an interview, E1 reported the key was left in the door knob because staff were doing laundry. In a later interview, E2 acknowledged poisonous or toxic materials stored by the assisted living facility were not maintained in a locked area and were accessible to residents.

Based on observation, documentation review, and interview, the licensee implemented a change without an approval or amended license issued by the Department. The deficient practice posed a risk as the Department had not reviewed the required documentation to approve or amend the license capacity. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a total of four resident beds throughout bedrooms one through three. 2. A review of Department documentation revealed AL12634 was licensed for five resident beds between four resident bedrooms. 3. A review of the facility's posted evacuation map revealed bedroom four was listed as a resident bedroom. 4. In an interview, E2 reported bedroom four was used by E1, and was not used as a resident bedroom. E2 acknowledged the licensee implemented a change without an approval or amended license issued by the Department.