Avista Sun City West Memory Care.

“Based on record review and interview, the manager failed to ensure that a manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provided evidence of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, and as specified in R9-10-113, for one of five personnel sampled. Findings include: 1 . A review of E1's personnel record revealed documentation of a negative TB blood test. However, documentation of a completed risk assessment and signs and symptom screening was not available for review at the time of inspection. 2 . In an exit interview, the findings were discussed with E1 and no additional information was provided.”

“Based on observation and interview, the manager failed to ensure if an assisted living facility maintained residents’ medical records electronically, that safeguards exist to prevent unauthorized access. Findings include: 1 . During an environmental inspection of the facility, the Compliance Officers observed a laptop on top of a medication cart in building C. The screen for the Medication Administration Record (MARs) was hidden from view. However, there was a second tab open that allowed the Compliance Officers to access resident medical records. This was also observed in buildings A and B. 2 . In an exit interview, the finding was discussed with E1 and no additional information was provided.”

“Based on documentation review and interview, the manager failed to ensure a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal. The deficient practice posed a risk to the physical health and safety of residents. Findings include: 1. A review of facility documentation revealed documentation of a fire inspection conducted by the local fire department on June 12, 2023. However, documentation of a fire inspection conducted by the local fire department before June 12, 2024 was not available for review at the time of inspection. 2. In an interview, E1 acknowledged a fire inspection was not conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of four employees reviewed, which required an employee to have a valid fingerprint card or submitted an application for a fingerprint card no more than 20 working days after the date of hire. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of November 22, 2023. The personnel record revealed no documentation of a fingerprint clearance card. However, a document printed from the Department of Public Safety's (DPS) website was available that showed an application was submitted to DPS dated November 20, 2023. The document showed the fingerprint clearance card was "In Process". 3. Review of E6's personnel record revealed E6 worked as an assistant caregiver and had a hire date of November 30, 2023. The personnel record revealed no documentation of a fingerprint clearance card. However, a document printed from the DPS website was available that showed an application was submitted to DPS dated January 16, 2024. The document showed the fingerprint clearance card was "In Process". 4. In an interview, O1, a DPS representative, reported a fingerprint application was received for E4 and E6, however E4's and E6's actual rolled fingerprints were not submitted. 5. In an interview, E1 and E2 acknowledged a fingerprint clearance card was not available for E4 and E6.”

“Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training, before providing assisted living services, for two of four caregivers reviewed. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency and the Department was provided false and misleading information. Findings include: 1. Review of the facility's policy and procedure revealed a policy titled "Maintaining Employee Records" that stated "Each employee or volunteer file will contain the following employment requirements:...3. Documentation of:...e. CPR training f. First Aid training..." 2. Review of the personnel records revealed the following: -E3's personnel record revealed E3 worked as a caregiver and had a hire date of May 2, 2023. The personnel record revealed a first aid card issued November 6, 2022 and a CPR card issued June 17, 2022. (This employee personnel record was reviewed during the compliant investigation conducted December 26, 2023. At that time, E3's personnel record included a CPR card from www.NationalCPRFoundation.com that was issued on September 19, 2023 and no other CPR training was available in the personnel record.) -E6's personnel record revealed E6 worked as an assistant caregiver and had a hire date of November 30, 2023. The personnel record revealed a first aid card issued November 6, 2022 and a CPR card issued June 17, 2022. -E3's and E6's first aid cards and CPR cards appeared falsified as they were not original, exactly the same (with the exception of the individuals name that was handwritten), and were photocopied. No additional documentation of first aid and CPR training was available for review. 3. Review of the January 2024 personnel schedule revealed the following: -E3 worked the 2pm-10:30pm shift January 3rd-5th and 10th, 11th, and 13th and the 10pm-6:30am shift January 3rd, 4th, 10th, 11th, and 13th. -E6 worked the 6am-2:30pm shift January 7th, the 2pm-10:30pm shift January 1st-4th, 7th-9th, and 11th, and the 10pm-6:30am shift January 13th. 4. In an interview, E1 and E2 acknowledged E3's and E6's first aid cards and CPR cards appeared falsified and current first aid and CPR training was not available. 5. This is an uncorrected deficiency from the complaint investigation conducted December 26, 2023.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's emergency contact and primary care provider, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a progress note dated December 25, 2023. This progress note stated "...resident was given (R2's) morning meds when resident stated (R2) was not feeling well then went unresponsive. Time resident was sent to the hospital: 9am ..." However, documentation was not available that showed R2's primary care provider was notified of this incident. 2. In an interview, E1 and E2 acknowledged R2's medical record did not include documentation that showed a caregiver immediately notified the resident's primary care provider. 3. This is an uncorrected deficiency from the complaint investigation conducted December 19, 2023.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R2's medical record revealed a progress note dated December 25, 2023. This progress note stated "...resident was given (R2's) morning meds when resident stated (R2) was not feeling well then went unresponsive. Time resident was sent to the hospital: 9am ..." However, the documentation did not include any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 and E2 acknowledged R2's medical record did not include documentation of any action taken to prevent the incident from occurring in the future. 3. This is an uncorrected deficiency from the complaint investigations conducted December 19, 2023, and December 26, 2023.”

“Based on record review and interview, the manager failed to ensure a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training before providing assisted living services. The deficient practice posed a health and safety risk if the employee did not know how to properly perform CPR. Findings include: 1. Review of E2 's (hired May 2023) personnel record revealed a CPR card that was obtained from www.NationalCPRFoundation.com, which was an online course. E2's CPR online certificate was issued on September 19, 2023. There was no other current documentation of CPR training available for review that would document that E2 had attended an approved CPR training course that included hands on demonstration of the employee's ability to perform CPR. 2. The compliance officer contacted a representative from NationalCPRFoundation who stated "Our courses are online only." 3. During an interview, E1 and E2 acknowledged E2 did not have current documentation of CPR training that included hands on demonstration ability to perform CPR.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of two residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R1's medical record revealed a progress note dated December 4, 2023 and December 6, 2023. The progress note for December 4, 2023 revealed 911 was called for "physically aggressive attempted to strike at caregiver". E1 reported 911 was called and transported R1 to the hospital and R1 was discharged returned to the facility the same day. The December 6, 2023 progress note revealed R1 assaulted R2. Documentation was not available that showed any action taken to prevent the incidents from occurring in the future. 2. In an interview, E1 and E2 acknowledged R1's medical record did not include documentation of any action taken to prevent the incidents from occurring in the future. This is an uncorrected deficiency from the complaint investigation conducted on December 19, 2023.”

“Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of five residents reviewed. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. Review of R1's medical record revealed a current written service plan dated December 11, 2023. This service plan indicated R1 received medication administration. 2. Review of R1's medical record revealed signed medication orders dated April 11, 2023. These medication orders stated the following: "Lisinopril Tablet 10mg Give 1 tablet by mouth one time a day Hold for BP [Blood Pressure] SBP [Systolic Blood Pressure] below 110 Diastolic below 60" "Midodrine HCL Tablet 10mg Give 1 tablet by mouth every 8 hours as needed for Systolic blood pressure less than 110" 3. Review of R1's medical record revealed a December 2023 medication administration record (MAR). This MAR stated the following: "Lisinopril Tablet 10mg Give 1 tablet by mouth one time a day Hold for BP SBP below 110 Diastolic below 60" and indicated the following: -R1's SBP was recorded below 110 at 8am on December 4th, 5th, 10th, 11th, and 12th. -R1's Diastolic blood pressure was recorded below 60 at 8am on December 4th. "Midodrine HCL Tablet 10mg Give 1 tablet by mouth every 8 hours as needed for Systolic blood pressure less than 110" and indicated the following: -R1's SBP was recorded less than 110 at 8am on December 4th, 5th, 10th, 11th, and 12th. However, the MAR did not indicated the medication was administered. 4. During an observation of R1's medications, the following was observed: Lisinopril 10mg was not available. Midodrine HCL 10mg was available. 5. In an interview, E2 reported Lisinopril had been not available since November 12, 2023. E1 and E2 acknowledged the medications were not administered in compliance with the available medication orders.”

“Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of five residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. Review of R3's medical record revealed a current written service plan dated December 9, 2023. This service plan indicated R3 received medication administration. 2. Review of R3's medical record revealed signed medication orders dated April 11, 2023. These medication orders stated the following: "Atorvastatin 80mg Tablet Give 1 tablet orally one time a day" "Donepezil HCL 5mg Tablet Give 1 tablet orally one time a day" "Gabapentin 600mg Tablet Give 1 tablet orally three times a day" "Glipizide ER 5mg Tablet Give 1 tablet orally one time a day" "Levothyroxine 50mcg Tablet Give 1 tablet orally one time a day" "Pantoprazole DR 40mg Tab Give 1 tablet orally one time a day" "Tamsulosin HCL 0.4mg capsule Give 1 capsule orally one time a day" 3. Review of R3's medical record revealed a December 2023 medication administration record (MAR). This MAR stated the following: "Atorvastatin 80mg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8pm December 8th - present. "Donepezil HCL 5mg Tablet Give 1 tablet rally one time a day" however, did not include documentation the medication was administered at 8pm December 8th - present. "Gabapentin 600mg Tablet Give 1 tablet orally three times a day" however, did not include documentation the medication was administered at 9am December 9th - present and at 2pm and 8pm December 8th - present. "Glipizide ER 5mg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8am December 9th - present. "Levothyroxine 50mcg Tablet Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 6am December 9th - present. "Pantoprazole DR 40mg Tab Give 1 tablet orally one time a day" however, did not include documentation the medication was administered at 8am December 9th - present. "Tamsulosin HCL 0.4mg capsule Give 1 capsule orally one time a day" however, did not include documentation the medication was administered at 5pm December 8th - present. 4. During an observation of R3's medications, the following was observed: Atorvastatin 80mg was available. Donepezil HCL 5mg was available. Gabapentin 600mg was available. Glipizide ER 5mg was available. Levothyroxine 50mcg was available. Pantoprazole DR 40mg was available. Tamsulosin HCL 0.4mg was available. 5. In an interview, E2 reported the medications were administered per the medication orders and E1 and E2 acknowledged R3's medical record did not include documentation the medications were administered.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver immediately notified the resident's primary care provider, for one of one resident reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a progress note dated December 11, 2023 at 02:01. This progress note stated "...Resident fell out of bed due to low blood sugar...Did the Resident require EMS due to any injuries or pain: yes...Was the Medical Practitioner notified...Will be contacting Doctor in the AM..." Documentation was not available that showed R4's primary care provider was immediately notified of this incident. 2. In an interview, E1 and E2 acknowledged R4's medical record did not include documentation that showed a caregiver immediately notified the resident's primary care provider of the incident.”

“Based on record review and interview, the manager failed to ensure when a resident had an incident that resulted in the resident needing medical services, a caregiver documented any action taken to prevent the incident from occurring in the future, for one of one residents reviewed who had an incident that resulted in the resident needing medical services. The deficient practice posed a health and safety risk. Findings include: 1. Review of R4's medical record revealed a progress note dated December 11, 2023 at 02:01. This progress note stated "...Resident fell out of bed due to low blood sugar...Did the Resident require EMS due to any injuries or pain: yes..." Documentation was not available that showed any action taken to prevent the incident from occurring in the future. 2. In an interview, E1 and E2 acknowledged R4's medical record did not include documentation of any action taken to prevent the incident from occurring in the future.”