Hummingbird Grove Peoria.

“Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. When the Compliance Officer arrived, E1, E2 and E3 were the only personnel members working at the facility. 2. During the environmental tour, the Compliance Officer observed there was no personnel schedule posted. The Compliance Officer requested the personnel schedule, however, E1 was not able to provide the work schedules for the month of September and October 2024. 3. In an interview, E1 reported that E1 was the only employee for the months of September and October. E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.”

“Based on observation, record review, and interview, the manager failed to ensure a complete personnel record was available for two of four personnel sampled. The deficient practice posed a risk as required information could not be verified for E2 and E3 and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. Upon arrival, the Compliance Officer was greeted by E1 at the door and observed E2 exiting a resident's room and E3 in the kitchen. 2. During a review of personal records, the Compliance Officer requested to review E2's and E3's personnel record, however, no personnel record for E2 and E3 was available for review at the time of the inspection. 3. In an interview, E1 reported E2 and E3 were assistant caregivers, and their personnel records were not available for review at the time of the inspection. E1 acknowledged a personnel record was not maintained for E2 and E3.”

“Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for one of four residents sampled. The deficient practice posed a risk as required information could not be verified for R4 and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. During the inspection, the Compliance Officer requested to review the medical records of R1, R2, R3, and R4 from E1, however, the medical record for R4 was not available for review at the time of the inspection. 3. In an interview, E1 reported that R4's medical record was unavailable for review. E1 reported that R4 was at the facility for less than 24 hours; however, E1 had failed to collect the required documentation before or at the time of R4's admission. E1 acknowledged that the medical record for R4 was not available for review during the inspection.”

“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. A review of the facility's policies and procedures revealed a document titled "Disaster plan, Relocation, Records, Medication, Food and Water". However, the disaster plan was reviewed last on February 22, 2023. 2. A review of facility policies and procedures revealed a policy "Disaster plan, Relocation, Records, Medication, Food and Water," the policy stated "8. The disaster plan is reviewed and the review is documented at least once every 12 months and includes the date and time of the disaster plan review, the name of each employee or volunteer participating in the disaster plan review, a critique of the disaster plan review, and if applicable, recommendations for improvement." 3. In an interview, E1 acknowledged there was no documentation available for review at the time of the inspection to indicate the disaster plan was reviewed at least once every 12 months.”

“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, labeled and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During the environmental tour, the Compliance Officer observed four ambulatory residents. 2. During the environmental tour, the Compliance Officer observed the following poisonous and toxic materials in an unlocked cabinet in a common bathroom: - one spray bottle of "WinCO Foods All Purpose Cleaner with Bleach" - one canister of "Pledge Lemon Enhancing Polish" - one jug of "LA's Totally Awesome Liquid Bleach Fresh Scent" 3. During the environmental tour, the Compliance Officer observed an unlocked laundry room. The following poisonous and toxic materials were observed: - one canister of "Pledge Lemon Enhancing Polish" - four spray bottle of "Febreze Air Freshener Spray" - two spray bottle of "PINALEN Multipurpose Cleaner Spray" - three spray bottle of "Clorox Original Clean-Up All Purpose Cleaner with Bleach Spray Bottle" - two jug of "LA's Totally Awesome Liquid Bleach Fresh Scent" 4. A review of facility documentation revealed a policy titled "Environmental and Physical Plant Safety," the policy stated "15. Poisonous and toxic materials will be in labeled containers and stored in a locked area separate from food preparation and food storage areas, dinning areas, and medications and are inaccessible to residents." 5. In an interview, E1 acknowledged poisonous and toxic materials stored by the assisted living facility were not maintained in a locked area inaccessible to residents. This is a repeat deficiency from the compliance inspection conducted June 23, 2023.”

“Based on observation and interview, the manager failed to ensure a resident bathroom used by more than one resident contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control. Findings include: 1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available for two of the common area bathrooms in the facility used by residents and visitors. 2. In an interview, E1 acknowledged the bathrooms used by more than one resident did not contained paper towels in a dispenser or a mechanical air hand dryer.”

“Based on observation and interview, the manager failed to ensure the swimming pool on the premises of the assisted living facility was enclosed by a wall or fence with a self-closing, self-latching gate that was locked when the swimming pool was not in use. The deficient practice posed a risk to the physical health and safety of residents with access to the swimming pool. Findings include: 1. The Compliance Officer observed four ambulatory residents in the facility. 2. During the inspection, the Compliance Officer observed R5 attempting to exit the facility multiple times without authorization and required staff redirection. 3. During the environmental tour, the Compliance Officer observed a swimming pool on the premises, however, the pool gate towards the casita was unlocked. The pool was found uncovered and filled with water. 4. In an interview, E1 acknowledged the swimming pool gate was unlocked.”