Lita Caring Home.

“Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training in fall prevention and fall recovery. Findings include: A review of facility policies and procedures revealed a policy covering fall prevention and fall recovery training was not available for review. A review of facility policies and procedures revealed a policy covering continuing education and in-services for staff. However, this policy did not cover fall prevention and fall recovery training. A review of E1's personnel record revealed fall prevention and fall recovery training was last documented in 2022. A review of R2's personnel record revealed fall prevention and fall recovery training was last documented in 2024. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the assisted living home failed to maintain a standardized form for each resident which included the information prescribed in subsection A, paragraph 1 of this section, for two of two sampled residents. A.R.S. § 36-420.04.A.1-9. States: Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and accountability act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives. Findings include: A review of R1's and R2's medical records revealed forms titled "Emergency Form." However, these forms did not include the following required items: A blank space to document the reason or reasons the emergency responder was requested on behalf of the resident. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. The name, address and telephone number of the resident's current pharmacy. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, before or at the time of acceptance, an individual submitted documentation, dated within 90 calendars days before acceptance, which stated 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 assistant, for two of two sampled residents. Findings include: A review of R1's medical record revealed a form titled "Pre-Admission Determination." The form included R1's name and was dated and signed by a registered nurse on R1's date of acceptance. The form stated R1 did not require restraints. However, the form did not state whether R1 required continuous medical services or continuous nursing services. A review of R2's medical record revealed a form titled "Pre-Admission Determination." The form included R2's name. However, the form was not signed or dated and did not state whether R1 required continuous medical services, continuous or intermittent nursing services, or restraints. A review of R2's medical record revealed a second form titled "Pre-Admission Determination." However, the form did not include R2's name. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure, for two of two sampled residents, a residency agreement included the date of occupancy or expected date of occupancy and whether the manager or a caregiver was awake during nighttime hours. Findings include: A review of R1's medical record revealed a residency agreement. The residency agreement included sections to document the date of acceptance and whether the manager or a caregiver was awake at night. However, both sections had been left blank. A review of R2's medical record revealed a residency agreement. The residency agreement included sections to document the date of acceptance and whether the manager or a caregiver was awake at night. However, both sections had been left blank. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure policies and procedures for medication administration were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: A review of the facility's policies and procedures revealed a medication policy which included a signature line for a medical practitioner, registered nurse, or pharmacist. However, this section had been left blank. In an exit interview with E1, the finding was reviewed and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked area. Findings include: During an environmental tour of the facility, the Compliance Officers observed a shared resident bathroom located down a short hallway from the front living room. Inside the bathroom, the Compliance Officers observed a cabinet above the sink which did not have a lock. Inside the cabinet, the Compliance Officers observed a container of "Gold Bond Medicated Powder." During an environmental tour of the facility, the Compliance Officers observed a refrigerator in the kitchen. The kitchen and the refrigerator were not secured and were accessible to residents. Inside the refrigerator, the Compliance Officers observed a metal box with a lock. However, the box was found to be left unlocked during the inspection. Inside the box, the Compliance Officers observed packages of Mounjaro, Bisacodyl, and Acetaminophen. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on document review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of evidence of freedom from infectious tuberculosis (TB), if required for the individual according to subsection (A)(8), for two of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. 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: b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201… ii. Annually obtaining documentation of the individual’s freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101”.   2. A review of E3’s personnel record revealed a document from the Pinal County Public Health, which stated E3 had a prior positive result, though stated, “No evidence of active TB”. The document had an expiration date of February 8, 2025. The document further stated for E3 to call their office two weeks prior to the expiration to renew the certificate by a review of signs and symptoms. 3. A review of E3's personnel record revealed E3 had been hired as a caregiver in February of 2024.   4. In an interview, E1 acknowledged the personnel file provided for E3 did not include documentation of evidence of freedom from infectious TB as required by R9-10-113. E1 acknowledged E3’s certification was expired.”

“Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings include: 1. The Compliance Officer observed at least twenty-four resident medical records, unlocked and scattered across a table in the dining room. There was a group of three visitors having a meeting with R4 at the next table. 2. The Compliance Officer observed more resident medical records, unsecured on a shelf in the living room.   3. In an interview, E1 reported E1 was working on the files prior to this Compliance Officer’s arrival.  4. In an interview, E1 acknowledged the resident's medical records were not protected from loss, damage, or unauthorized use, while stored on a shelf in the living room or on a table in the dining room.”

“Based on documentation review and interview, the manager failed to ensure a caregiver or an assistant caregiver immediately notified the resident's emergency contact when a resident had an accident, emergency, or injury that resulted in the resident needing medical services.   Findings include: 1. A review of facility incident reports revealed an incident report for R3, dated August 25, 2024, at 10:50 am. The incident report stated, while changing R3’s brief, E2 noticed a skin tear on R3’s right arm. The document further stated E2 provided first aid by cleaning the wound, applying a bandage, and taking vitals. The incident report detailed a call was made to the manager and the hospice service; however, there was no notification to R3’s emergency contact.   2. Another incident report regarding R3 was reviewed, which was dated September 11, 2024 at 6 am. The incident report reported E2 was in R3’s room fixing bedding while R3 was seated in a wheelchair. R3 fell out of the wheelchair causing a skin tear above the eyebrow. The document details first aid was provided by cleaning the wound and applying a bandage. E2 documented notifying the manager and the hospice service; however, there was no notification to R3’s emergency contact.  3. In an interview, E1 acknowledged the incident reports for R3 did not include documentation of the immediate notification of R3's emergency contact. E1 reported hospice was to notify the family, though acknowledged it was the manager’s responsibility, not hospice.”

“Based on record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before providing physical health services, and according to policies and procedures for two of two personnel members sampled. The deficient practice, posed a risk to the health and safety of residents if a caregiver was unable to meet the needs of residents. Findings include: 1. A review of E2's personnel record (hired on February 22, 2015), did not reveal documented evidence E2's skills and knowledge had been verified. 2. A review of E3's personnel record, (hired on January 30, 2020), did not reveal documented evidence E3's skills and knowledge had been verified. 3. In an interview, E1 acknowledged E2's and E3's personnel records did not reveal documented evidence E2's and E3's skills and knowledge had been verified before providing physical health services or behavioral health services to residents.”

“Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113, for two of two residents sampled. Findings include: 1. A review of R1's medical record (admitted in 2022) did not reveal evidence of freedom from TB, dated before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113. 2. A review of R2's medical record (admitted in 2023), did not reveal evidence of freedom from TB, dated before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113. 3. In an interview, E1 acknowledged R1's and R2's medical records did not reveal evidence of freedom from TB, dated before or within seven calendar days after the resident's date of occupancy, and as specified in R9-10-113.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan that was completed no later than 14 days after the resident's date of acceptance for one of two residents sampled. The deficient practiced posed a risk to the health and safety of residents if a service plan was not completed, detailing how the resident's needs would be met. Findings include:. 1. A review of R2's medical record (admitted in 2023), revealed an incomplete service plan. Therefore, the service plan was not completed no later than 14 days after the resident's date of acceptance. 2. In an interview, E1 acknowledged R2's medical record did not reveal a completed service plan, which was completed no later than 14 days after the resident's date of acceptance..”

“Based on documentation review, record review and interview, the manager failed to ensure a resident's medical record contained documentation of notification of the resident of the availability of vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d) for one of three sampled residents. Findings include: According to A.R.S. 36-406(1)(d) 1. The Department shall: (d) 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. 2. A review of R1's medical record did not reveal documented evidence of an offer for a vaccination for influenza and pneumonia to R1. 3. In an interview, E1 acknowledged R1's medical record did not reveal evidence of an offer for a vaccination for influenza and pneumonia to R1, according to A.R.S. 36-406(1)(d).”