Willow Canyon LLC

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for five of five employees reviewed. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of E2's, E3's, E4's, E5's, and E6's personnel record revealed two Mantoux skin tests dated within 12 months of each other as required for employees. However, a baseline symptom screening signed by a registered nurse, medical practitioner or local health department was not provided for review. 3. In an interview, E2 acknowledged E2, E3, E4, E5, and E6 did not provide documentation of freedom from infectious TB as specified in R9-10-113.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for five of six employees sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E1, E2, E3, E4, and E5 were fit to work at the assisted living facility. Findings include: 1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency." 2. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers was made to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an interview, E2 acknowledged E1's, E2's, E3's, E4's, and E5's personnel records did not include the documentation required in A.R.S. \'a7 36-411(C)(1). E3 acknowledged the reference checks were not done.

Based on record 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, if the individual was requesting or was expecting to receive supervisory care services, personal care services, or directed care services, included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician's assistant, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed there was no documentation indicating whether R1 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. 2. In an interview, E2 acknowledged R1's medical record did not contain documentation that was dated within 90 days before the individual was accepted by the assisted living facility and was signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant. After a review of R1's medical record, E2 stated, "To be honest, we don't have it."

Based on record review 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 sampled. The deficient practice posed a risk of a medication error if medication administered to a resident was not documented. Findings include: 1. A review of R2's medical record revealed a service plan dated January 15, 2024. The service plan revealed R2 received medication administration. 2. A review of R2's medication administration record (MAR) revealed R2 received medication administration of the following medications with PM administration: -Sulfasalazine 500 mg, two tablets at 5:00 PM; -Naproxen Sodium 220 mg, one tablet at 5:00 PM -Haloperidol 0.5 milligrams (mg), one tablet at 12:00 PM and 8:00 PM; and -Atorvastatin 20 mg, one tablet at 8:00 PM; 3. A review of R2's medication organizer revealed individual compartments for Morning, Noon, Evening, and Bedtime medications. The Compliance Officer observed five tablets in the evening compartment and confirmed they were the medications scheduled for administration at 5:00 PM and 8:00 PM. The bedtime compartment was empty. 4. In an interview, E2 reported all evening and bedtime medications were administered at 8:00 PM, not separately at 5:00 PM and 8:00 PM as documented on the MAR. E2 acknowledged the time of medication administration of the aforementioned medications was not being accurately documented.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were not prescribed the accessible medication. Findings include: 1. Upon entry into the facility, the Compliance Officer observed a medication cart with the locking mechanism out, indicating the medication cart was unlocked. The keys were also hanging in the lock. 2. During a review of R2's medications, the Compliance Officer observed E4 take a lockbox out of the refrigerator. There was a small padlock on the lockbox. However, the padlock was not locked and the Compliance Officer observed medication was stored inside. 3. In an interview, E2 acknowledged the manager failed to ensure medication was 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 a smoke detector was tested at least once a month. The deficient practice posed a health and safety risk if the smoke detectors did not work properly during an emergency. Findings include: 1. During a tour of the facility, the Compliance Officer observed there was no fire alarm system installed at the facility. 2. In an interview, the Compliance Officer requested monthly smoke detector testing documentation. A review of facility records revealed smoke detector testing documentation was not available for review. 3. In an interview, E2 acknowledged E2 did not have smoke detector testing documentation. E2 stated, "I believe they work."

Based on documentation review and interview, the governing authority failed to designate, in writing, an acting manager, if the manager was expected not to be present or was not present on the assisted living facility's premises for more than 30 calendar days. The deficient practice posed a risk to the health and safety of the residents as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility. Findings include: 1. A review of Department documentation revealed the Compliance Officer was on-site at AL10614 for a compliance inspection on June 27, 2023. 2. While on-site on June 27, 2023, the Compliance Officer observed E5's manager's certificate hanging on the facility's wall. The Compliance Officer communicated to E3 and E4 that the Department had not received notification of E5's appointment as manager of the facility. 3. Upon hearing the aforementioned information from the Compliance Officer, E4 emailed the Department and reported that E5 was the facility's manager, effective April 1, 2023. 4. In an email to the Department received on or around November 28, 2023, E5 reported E5 had been out of the country since June 23, 2023. E5 included documentation of E5's flight information showing that E5 left the country for the Philippines on June 23, 2023 with a return date of December 22, 2023. 5. In an on-site complaint investigation conducted December 1, 2023, the Compliance Officer observed E1's manager's certificate hanging on the facility's wall. The Compliance Officer communicated to E2 and E3 that the Department had not received notification of E1's appointment as manager of the facility. 6. In an interview, the Compliance Officer asked who managed the facility while E5 was out of the country. E2 and E3 believed E5 to be the manager. E2 and E3 reported not being aware that if the manager was expected not to be present or was not present on the assisted living facility's premises for more than 30 calendar days, an acting manager must be appointed.

Based on observation, documentation review and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager. Findings include: 1. In an on-site complaint investigation, the Compliance Officer observed E1's manager's certificate conspicuously posted in the facility. 2. A review of Department documentation revealed an email dated June 27, 2023 from E4. The email indicated O1 was the facility's manager effective April 1, 2023. However, there was no documentation to indicate E1 was the new manager. 3. In an interview, E2 and E3 reported E1's date of hire as the manager of the facility was November 15, 2023. E2 and E3 reported to believe E1 notified the Department of the facility's change of manager, but E2 and E3 were not sure. This is a repeat deficiency from the compliance inspection conducted June 27, 2023.

Based on documentation review, observation, 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. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager Findings include: 1. A review of Department documentation indicated O1's appointment as manager ended September 10, 2022. There was no notification of a new manager appointed. 2. A review of Department documentation indicated as of December 7, 2022, O2 was the facility's manager. However, there was no documentation submitted to the Department that indicated there was a change in manager. 3. In an on-site compliance inspection, E2 and E4 reported E1 had been appointed manager effective April 1, 2023. However, there was no documentation submitted to the Department that indicated there was a change in manager. 4. In an interview, E4 acknowledged the Department was not notified of a change in the manager as required. 5. In an email received by the Department on June 27, 2023, the Department was notified of E1's appointment as manager effective April 1, 2023.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked. The deficient practice posed a risk if there was no record to ensure shifts and tasks were covered by qualified individuals. Findings include: 1. Upon arrival to the facility, the Compliance Officer observed E2 and E3 working on the premises. 2. A review of facility documentation revealed a policy titled, "Staff Schedule."The policy stated, "A staff (personnel) schedule must be generated and followed to ensure residents are getting the care they need." Under the title "Procedures," the document stated: "1. The manager is responsible for generating a staff schedule for the facility. 2. It must include name of employee, date and schedules [sic] work hours. 3. The staff schedule must be posted and generated at least seven days in advance. 4. Any changes must be done directly on the personnel schedule of actual hours worked and maintained on the premises for twelve months." 3. During the on-site complaint inspection, the Compliance Officer requested the current personnel schedule as well as the last 12 months of personnel schedules, including the hours worked for each employee. E2 provided a schedule for the months of May 2023 and June 2023. No additional schedules were provided for review. 4. In an interview, E2 and E4 acknowledged documentation of the caregivers and assistant caregivers working each day, including the hours worked, was not maintained and accurate. E2 and E4 reported the facility was under new management and the requested schedules were not available for review.

Based on documentation review, record review, and interview, the manager failed to ensure a resident had a written service plan that was developed with assistance and review from the resident's representative and a nurse or medical practitioner, for two of two residents. The deficient practice posed a risk if R1's and R2's representatives and a nurse or medical practitioner were unable to participate in the development or review the service plans to provide essential information about R1's and R2's needs. Findings include: 1. A review of facility documentation revealed a policy titled, "Developing and Updating Service Care Plans." The policy stated, "The manager or manager's designee is responsible in consulting with the registered nurse and develop a service care plan for each resident in the facility and also updating the service care plan depending on the level of care for each resident." 2. A review of R1's medical record revealed a service plan dated May 2, 2023. The service plan indicated R1 received directed care services and medication administration. However, the service plan was not signed by R1's representative and a nurse or medical practitioner as required. 3. A review of R2's medical record revealed a service plan dated May 5, 2023. The service plan indicated R2 received directed care services and medication administration. However, the service plan was not signed by R2's representative and a nurse or medical practitioner as required. 4. In an interview, E2 and E4 acknowledged R1's and R2's service plans were not signed to indicate the service plans were developed and reviewed by R1's and R2's representatives and a nurse or medical practitioner.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, 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 and provided access to an outside area which allowed the resident to be 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 documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility, the Compliance Officer observed when exiting from the patio door to the backyard, no alarm sounded to alert employees of the egress of a resident from the facility. The Compliance Officer observed an alert system was installed on the patio door. However, the alert system was not functioning. 3. In an interview, E2 and E4 acknowledged the aforementioned door did not alert employees of the egress of a resident from the facility. This is a repeat deficiency from the on-site inspection completed November 19, 2021.

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for two of two sampled residents. 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 R1's medical record revealed a medication administration record (MAR) dated June 2023. The MAR indicated R1 received several medications, including the following: -Mirtazapine 15 milligrams (mg), every day; -Senna 8.6 mg, 2 tablets as needed at bedtime; -Meclizine 25 mg, as needed; and -Lidocaine Patch 4%, as needed. 2. A review of R1's medical record revealed no signed medication orders for the aforementioned medications. 3. A review of R2's medical record revealed a medication administration record (MAR) dated June 2023. The MAR indicated R2 received the following medications: -Losartan 100-12.5 mg, every day; -Metformin 1000 mg, twice a day; -Tamsulosin 0.4 mg, every day; -Metoprolol 100 mg, twice a day; -Tylenol 500 mg, every four hours as needed; -Cephalexin 250 mg, twice a day; and -Tizanidine 2 mg, at bedtime. 4. A review of R2's medical record revealed no signed medication orders for the aforementioned medications. In addition, the Compliance Officer observed an unsigned medication list that included Digoxin 125 mcg every day and Tylenol PM 500 mg/25 mg at bedtime. The Compliance Officer observed the medications in R2's medication bin. However, the aforementioned medications were not on the MAR or in R2's mediset as being administered. E2 confirmed the medications were not being administered. 5. E2 and E4 acknowledged the aforementioned medication administered to R1 and R2 was not administered in compliance with a medication order as no signed orders were available for review. E2 reported E2 would contact R1's and R2's hospice agencies to request signed medication orders as required.