Winilyn Home LLC

Based on documentation review, record review, and interview, the manager of an assisted living center who contacted emergency responders on behalf of a resident failed to provide to the emergency responders a written document that included all information required in A.R.S. \'a7 36-420.04, for one of three residents sampled. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of facility documentation revealed an incident report dated November 8, 2024. The incident report revealed the facility called emergency medical services due to R2 not feeling well and back pain expressed. 2. A review of R2's medical record revealed no documentation of the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). 3. In an interview, E1 acknowledged the documentation provided to emergency medical services did not include all the information required in A.R.S. \'a7 36-420.04.

Based on observation, documentation review, and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication. Findings include: 1. During the facility tour with E2, the Compliance Officer observed a cabinet located outside of the staff office that held nine residents' medications unlocked. This cabinet had a lock, however the cabinet was not locked. 2. Review of the facility policy and procedure documentation revealed a policy titled "Medication Services" which stated: "All resident medications must be secured in a locked storage area." 3. In an interview, E2 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who were confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated November 7, 2023. This service plan stated "Mobility/Transfer - Needs full assistance". 2. Review of R2's medical record revealed no documentation indicating R2's medical practitioner examined R2 upon the onset of the condition and every six months thereafter, signed and dated a determination that stated R2's needs could be met by the facility, and reviewed the facility's scope of services. 3. In an interview, E1 reported R2 was unable to ambulate even with assistance for approximately four months and acknowledged R2's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who had a stage 3 or stage 4 pressure sore, unless the facility obtained a written determination from a medical practitioner, upon the onset of the condition and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents reviewed who had a stage 3 or stage 4 pressure sore. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated November 7, 2023. This service plan was signed by a registered nurse and stated "Resident does have a stage 3 wound on right heal". 2. Review of R2's medical record revealed no documentation indicating R2's medical practitioner examined R2 upon the onset of the condition and every six months thereafter, signed and dated a determination that stated R2's needs could be met by the facility, and reviewed the facility's scope of services. 3. In an interview, E1 acknowledged R2's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

Based on documentation review and interview, the manager failed to ensure the facility's disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Disaster plan, Relocation, Records, Medication, Food and Water." Documentation was available in the policy and procedure that showed the disaster plan was last reviewed November 15, 2022. 2. In an interview, E1 acknowledged the facility's disaster plan was not reviewed at least once every 12 months.