Inspection Reports for Agape Care Home of Scottsdale
5920 E Ludlow Dr, Scottsdale, AZ 85254, AZ, 85254
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Inspection Report
Complaint Investigation
Capacity: 10
Deficiencies: 15
Jun 6, 2024
Visit Reason
State-compiled facility profile showing 3 inspections from 2023-05 to 2024-06 with deficiency history including complaint and annual compliance inspections.
Findings
Across all inspections, multiple deficiencies were found including failures in documentation, medication administration, resident service plans, staff training, and safety protocols. Several complaint investigations revealed risks to resident health and safety due to incomplete records, improper medication handling, and inadequate follow-up on incidents.
Complaint Details
The complaint investigations included complaints #AZ00210929, #AZ00210682, #AZ00210281, and AZ00195159, with findings of multiple deficiencies related to resident care, documentation, and safety.
Deficiencies (15)
| Description |
|---|
| L. If a resident is receiving services from a home health agency or hospice service agency, a manager shall ensure that: 1. The resident's medical record contains: a. The name, address, and contact individual, including contact information, of the home health agency or hospice service agency; b. Any information provided by the home health agency or hospice service agency; and c. A copy of resident follow-up instructions provided to the resident by the home health agency or hospice service agency; - Failed to ensure a resident's medical record contained any information provided and follow up instructions provided by a Hospice service agency. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: c. The amount, type, and frequency of assisted living services being provided to the resident, including medication administration or assistance in the self-administration of medication; - Failed to ensure a resident's written service plan included the amount, type, and frequency of assisted living services being provided. |
| C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident's medical record; and - Failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, including false and misleading information. |
| B. A manager of an assisted living facility authorized to provide directed care services shall not accept or retain a resident who, except as provided in R9-10-814(B)(2): 1. Is confined to a bed or chair because of an inability to ambulate even with assistance; or - Failed to meet requirements for residents unable to walk even with assistance, including missing required documentation. |
| B. If an assisted living facility provides medication administration, a manager shall ensure that: 2. Policies and procedures for medication administration: c. Ensure that medication is administered to a resident only as prescribed; and - Failed to ensure medication was administered only as prescribed; a resident was given the wrong medications. |
| F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication; - Failed to ensure policies and procedures were implemented for discarding medication; medications of former residents were not discarded as required. |
| F. When medication is stored by an assisted living facility, a manager shall ensure that: 3. Policies and procedures are established, documented, and implemented for: d. Storing, inventorying, and dispensing controlled substances. - Failed to ensure policies and procedures were implemented for inventorying controlled substances; medication inventory was incomplete. |
| C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 4. Potentially hazardous food is maintained as follows: a. Foods requiring refrigeration are maintained at 41° F or below; and - Failed to ensure foods requiring refrigeration were maintained at 41° F or below. |
| R9-10-120. Opioid Prescribing and Treatment F. For a health care institution where opioids are administered as part of treatment or where a patient is provided assistance in the self-administration of medication for a prescribed opioid, including a health care institution in which an opioid may be prescribed or ordered as part of treatment, a medical director, a manager as defined in R9-10-801, or a provider, as applicable to the health care institution, shall: 4. Except as provided in subsection (H), ensure that an individual authorized by policies and procedures to administer an opioid in treating a patient or to provide assistance in the self-administration of medication for a prescribed opioid: a. Before administering an opioid or providing assistance in the self-administration of medication for a prescribed opioid in compliance with an order as part of the treatment for a patient, identifies the patient's need for the opioid; b. Monitors the patient's response to the opioid; and c. Documents in the patient's medical record: i. An identification of the patient ' s need for the opioid before the opioid was administered or assistance in the self-administration of medication for a prescribed opioid was provided, and ii. The effect of the opioid administered or for which assistance in the self-administration of medication for a prescribed opioid was provided. - Failed to ensure documentation of resident's need for opioid and monitoring of effect. |
| A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and - Failed to ensure a resident's written service plan was reviewed and updated no later than 14 calendar days after a significant change. |
| D. When a resident has an accident, emergency, or injury that results in the resident needing medical services, a manager shall ensure that a caregiver or an assistant caregiver: 2. Documents the following: f. Any action taken to prevent the accident, emergency, or injury from occurring in the future. - Failed to ensure documentation of actions taken to prevent future accidents or injuries for multiple residents. |
| 36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. - Failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. |
| C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: c. Documentation of: vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii. First aid training, if required for the individual in this Article or policies and procedures; and - Failed to ensure personnel record included documentation of current CPR and first aid training for one employee. |
| B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and 2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility: a. Includes whether the individual requires continuous behavioral health services, and b. Is signed and dated by a behavioral health professional. - Failed to ensure required documentation dated within 90 days before acceptance was submitted for one resident. |
| A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position; - Failed to ensure oxygen containers were secured in an upright position; two cylinders were unsecured. |
Report Facts
Inspections on page: 3
Total deficiencies: 15
Complaint Inspections: 2
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