VISTA LIVING CAMELBACK

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed an undated policy titled "Fall Prevention and Recovery Training." The policy stated "Procedure 1. \ [sic] has partnered with a training provider to provide and deliever training for employees on Fall Prevention and Fall Recovery...2. The provider's curriculum is based on information and training materials established by the Arizona Fall Prevention Coalition...5. The training provider will issue verifiable certificates for students who complete the curriculum..."

2. A review of E2's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

3. In an interview, E1 reported E2 completed fall prevention and fall recovery training, however, the documentation was not at the facility. E1 acknowledged the facility had not administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of E4's personnel record revealed E4 was hired as a caregiver. However, documentation to demonstrate E4 provided evidence of freedom from infectious TB was not available for review.

2. A review of R2's medical record revealed a document titled "VISTA LIVING CAMELBACK INFLUENZA/PNEUMONIA VACCINE LOG". The document stated "I understand the benefits of receiving and the risks of NOT RECEIVING the INFLUENZA VACCINE, and have been offered the influenza vaccine." A box which stated "I accept (with my physician's order)" was marked, indicating R2 received the influenza vaccine. Additionally, the document stated "I understand the benefits of receiving and the risks of NOT RECEIVING the PNEUMONIA VACCINE, and have been offered the pneumonia vaccine." A box which stated "I accept (with my physician's order)" was marked, indicating R2 received the pneumonia vaccine. However, the document was signed by O1, R2's representative and was dated in 2021, and documentation of influenza and pneumonia available to R2 on site on a yearly basis, was not available for review.

3. A review of E2's record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

4. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request.

Based on 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), for one of three employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of E4's personnel record revealed E4 was hired as a caregiver. However, documentation to demonstrate E4 provided evidence of freedom from infectious TB was not available for review.

2. In an interview, E1 reported E4 had a TB test, however, E1 was unable to locate E4's documentation of freedom from infectious TB. E1 acknowledge documentation of E4's TB test was not available for review.

Based on 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 influenza and pneumonia, according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d), for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A.R.S. \'a7 36-406(1)(d) states: "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. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized."

2. A review of R2's medical record revealed a document titled "VISTA LIVING CAMELBACK INFLUENZA/PNEUMONIA VACCINE LOG". The document stated "I understand the benefits of receiving and the risks of NOT RECEIVING the INFLUENZA VACCINE, and have been offered the influenza vaccine." A box which stated "I accept (with my physician's order)" was marked, indicating R2 received the influenza vaccine. Additionally, the document stated "I understand the benefits of receiving and the risks of NOT RECEIVING the PNEUMONIA VACCINE, and have been offered the pneumonia vaccine." A box which stated "I accept (with my physician's order) was marked, indicating R2 received the pneumonia vaccine. However, the document was signed by O1, R2's representative and was dated in 2021, and documentation of influenza and pneumonia available to R2 on site on a yearly basis, was not available for review.

3. In an interview, E1 reported the influenza and pneumonia vaccines were offered to R2, however E1 could not locate the documentation. E1 acknowledged documentation of R2's yearly notification of the availability of vaccination for influenza and pneumonia, according to A.R.S. \'a7 36-406(1)(d), was not available for review.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. The deficient practice posed a risk if the facility was unaware of a resident's general or specific whereabouts.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Wandering" dated April 20, 2020. The policy stated "5. If alarms are being used on doors and/or windows, the caregiver will check them daily for operation and security."

2. A review of Department documentation revealed AL10620 was authorized to provide directed care services.

3. The Compliance Officer observed a door leading out to the back yard. The Compliance Officer observed the outside area in the back yard allowed residents to be at least 30 feet away from the facility. The Compliance Officer observed the door leading out to the back yard contained an alarm, however, the alarm did not alert employees to the egress when the door leading out to the back yard was opened.

4. The Compliance Officer observed R3's bedroom contained a door leading out to the back yard. The Compliance Officer observed the outside area in the back yard allowed residents to be a least 30 feet away from the facility. The Compliance Officer observed the outside area contained a locked gate. The Compliance Officer observed the door leading to the back yard contained an alarm, however, the alarm did not control or alert employees of egress

5. In an interview, E1 reported the alarms were not operating, and a maintenance person was on-site fixing the alarms. E1 acknowledged the doors leading to the outside areas did not control or alert employees of the egress of a resident.