Immaculate Assisted Living, LLC.

“Based on documentation review, record review, and interview, the manager failed to ensure that the assisted living home that contacted emergency responders on behalf of a resident provided to the emergency responders a copy of the resident's health insurance portability and accountability act (HIPAA) release authorizing the receiving hospital to communicate with the assisted living home to plan for the resident's discharge. Findings include: 1. A review of R2's medical record revealed no documentation of a HIPAA release form. 2. In an interview, E1 reported that the EMS packet that was provided was everything that was given to emergency services. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on record review, documentation review, and interview, the manager failed to provide written notification to the Department of a resident’s death, if the resident’s death was required to be reported according to A.R.S. § 11-593, within one working day after the resident’s death. Findings include: 1. A.R.S. § 11-593 classifies reportable deaths to include "unexpected or unexplained deaths". 2. A review of R1's medical record revealed a document titled "Narrative Notes" regarding a fall, which required emergency medical services to come to the facility to take R1 to the hospital. 3. A review of Department documentation revealed R1 had passed away due to "Complications of Right Femur Fracture". The department did not receive notification of R1's death from the facility. 4. In an exit interview, the findings were reviewed with E1, and no additional information or documentation was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with medication orders and documented in the resident's medical record. Findings include: 1. A review of the facilities' policies and procedures revealed a document titled "Medication Administration" , which stated "It is the policy of the facility to administer medication to all residents unless the resident's physician indicates in writing that a resident is safe to administer their own medications. All medication orders for resident at the facility will be reviewed by a license nurse and administered by a certified caregiver. The certified caregiver will monitor the resident's taking of medication and will stay with the resident until all medicines have been taken and swallowed. All refusals and inability to take medications will be documented in the Medication Administration Record ( MAR ) and reported to the Facility Manager, the resident's representative and the primary care physician. The facility Medication Administration Program will follow Arizona Regulations". 2. A review of R2's medical records revealed current medication orders, which listed the following medications: SENNA 8.6 MG TAKE 2 TABLET PO TWICE DAILY DOCUSATE 100mg TAKE 1 CAPSULE PO TWICE DAILY DULOXETINE 20MG TAKE 5 CAPSULE PO DAILY POLYETHYLENE 3350 TAKE 1 CAPFUL PO TWICE DAILY LORAZEPAM 1MG TAKE 1 TABLET PO TWICE DAILY FOR ANXIETY OLANZAPINE 10MG TAKE 1 TABLET PO 3. A review of R2's medication administration record for February revealed no documentation of any of the listed medications above on the following dates: 18th, 20th, 21st, and 22nd. 4. In an interview, E1 reported that medication was provided. 5. In an interview, the findings were reviewed with E1, and no additional documentation or information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure the caregiver documented the time of an accident, emergency, or injury, and any actions taken to prevent the accident, emergency, or injury from occurring in the future. Findings include: 1. A review of the facilities policies and procedures revealed a document titled "Accident, Incident, or Injury Affecting Resident", which stated "Care Manager or Nurse documents the following: a. Date and time of the accident, incident or injury... f. Action taken to prevent the accident, incident or injury from occurring in the future;" and a "Incident Report Form". 2. A review of R1's medical record revealed a document titled "Narrative Notes" regarding a fall, which required emergency medical services to come to the facility to take R1 to the hospital. The document did not contain the time or any action taken to prevent the accident, emergency, or injury from occurring in the future. 3. In an interview, the findings were reviewed with E1, and no additional documentation or information was provided.”

“Based on observation and interview, the manager failed to ensure the premises and equipment at the assisted living were free from a condition or situation that may cause a resident or other individual physical injury. Findings include: 1. During an environmental inspection of the backyard, the Compliance Officer observed two toilets on the ground, a chain hanging over an electricity box, and wood sheathing leaning against a shed. 2. In an interview, E1 reported that they have plans to fix the yard. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure that poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. Findings include: 1. During an environmental inspection of the backyard, the Compliance Officer observed two cans of Valspar exterior paint and primer. One was empty, the other had liquid inside. The Compliance officer informed E1, and E1 poured the blue liquid onto the ground. 2. In an interview, E1 reported that it was empty and the water inside was just rainwater. 3. In an interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on observation, documentation review, record review and interview, the manager failed to designate, in writing, a caregiver who was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk 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. When the Compliance Officer arrived, E3 was the only staff member present at the facility. 2. Review of facility documentation revealed a document titled "Delegation of Manager's Authority" which revealed E5 was the only caregiver designated in writing to be accountable for the assisted living facility when the manager is not present on the assisted living facility premises. 3. Review of E3's personnel record revealed that E3's position was "assistant caregiver". 4. In an interview, E1 acknowledged a caregiver who was designated in writing was not present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present.”

“Based on observation, record review, and interview, the manager failed to ensure that at least the manager or a caregiver was present at the assisted living home when residents were present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. When the Compliance Officer arrived, E3 was the only staff member present at the facility. 2. Review of E3's personnel record revealed that E3's position was "caregiver assistant" and that E3 was not a certified caregiver. 3. In an interview, E1 acknowledged that at least the manager or a caregiver was not present at the assisted living home when residents were present.”

“Based on record review and interview, the manger failed to ensure that the residency of a resident was terminated with a 30-calendar-day written notice of termination. The deficient practice posed a risk as R1's rights were violated. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that the residency of R1 was terminated without a 30-calendar-day written notice of termination.”

“Based on record review and interview, the manager failed to ensure that a written notice of termination was provided to a resident. The deficient practice posed a risk as R1's rights were violated. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that R1 was not provided a written notice of termination.”

“Based on record review and interview, the manger failed to ensure that a resident's medical record contained the date of termination for a resident for 1 of 1 terminated residents reviewed. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. The Compliance Officer observed that R1 was not present at the facility during the inspection. 2. Review of R1's medical record revealed no documented date of termination or written notice of termination. 3. In an interview, E1 reported that R1 went to the hospital but did not provide the date. E1 reported that R1's residency was terminated due to behaviors and was not allowed to return to the facility from the hospital. 4. In an interview, E1 acknowledged that R1's medical record did not contain the date of termination.”

“Based on observation and interview, the manger failed to ensure that the premises were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential egress dangers to residents. Findings include: 1. In an unlocked caregiver room, the Compliance Officer observed a mattress propped up against a wall which blocked a door to the outside that had an "EXIT" sign above it. 2. In an interview, E1 acknowledged that the premises were not free from a condition or situation that may cause a resident or other individual to suffer physical injury.”

“Based on observation and interview, the manager failed to ensure heating and cooling systems maintained the assisted living facility at a temperature between 70° F and 84° F at all times. The deficient practice posed a risk to health and safety. ​ Findings include: ​ 1. The Compliance Officer observed the facility thermostat reading 31.5℃ (88.7 ℉). On a Department issued thermometer, the Compliance Officer observed a temperature of 87.8℉ in the facility. 2. In an interview, E1 acknowledged that heating and cooling systems did not maintain the assisted living facility at a temperature between 70° F and 84° F at all times.”