THE FORUM AT DESERT HARBOR

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees or volunteers did not possess the skills and knowledge to ensure the health and safety of residents.

Findings include:

1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented at the time of the inspection.

2. In an interview, E1 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.

Based on observation and interview, the manager failed to ensure a toxic material stored by the facility was stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of residents with access to the materials.

Findings include:

1. During an environmental inspection of the facility, the Compliance Officers observed an unlocked door titled "Resident Laundry" on the second floor of the facility. Inside the laundry room was a block of home-style solid laundry detergent and a detergent dispenser filled with a block of home-style laundry detergent. Further observation included bottles of "RX Destroyer" drug disposal, "DermaKlenz" wound cleanser, "Kendall" saline wound solution, a block of home-style solid laundry detergent, a detergent dispenser filled with a block of home-style laundry detergent and a laundry detergent pod located on top of a pile of laundry in the "Resident Laundry" room on the third floor.

2. During an environmental inspection of the facility, the Compliance Officers observed a can of "Rust-oleum" paint and primer located in a unlocked cabinet in the activity room.

3. In an interview, E1 acknowledged toxic material stored by the facility was accessible to residents.

Based on documentation review and interview, the governing authority failed to notify the Department according to Arizona Revised Statutes (A.R.S.) \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of Department documentation revealed O1 was the manager for AL11298 as of January 12, 2023.

2. In an interview, E1 reported E1 became the new manager on August 17, 2023.

3. A review of Department documentation revealed evidence to indicate the governing authority notified the Department when there was a change in the manager and identify the name and qualifications of the new manager was not available.

4. In an interview, E1 acknowledged the facility did not notify the Department of a change in the facility's manager.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for one of four individuals hired as caregivers. The deficient practice posed a risk if E3 was not qualified to provide the required services.

Findings include:

1. A review of facility documentation revealed a staffing schedule for August 2023. The staffing schedule revealed E3 was scheduled to work 10:00 PM - 6:30 AM on August 2, 3, 6, 9, 10, 14, 16, 17, 23, 24, 25, 27, 28, 30, 2023.

2. A review of E3's (re-hired in 2023) personnel record revealed E3 was hired as a caregiver. E3's personnel record revealed documentation of completion of a caregiver training program (issued August 13, 2008) from "RSAA - #ALTP0063".

3. A review of the NCIA Board website for caregiver training programs (https://nciaboard.az.gov/news/caregiver-certificate-verification) revealed RSAA - #ALTP0063 was in operation from July 3, 2000 to July 31, 2008.

4. A review of https://az.tmuniverse.com revealed E3 had not completed a caregiver training program.

5. In an interview, E1 and E2 acknowledged E3 had not completed a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers.

This Rule was cited during the compliance inspection conducted on December 30, 2020, and the off-site documentation review conducted on January 6, 2021.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication.

Findings include:

1. The Compliance Officer observed multiple ambulatory residents on the premises.

2. The Compliance Officer observed an open medication room. The Compliance Officer observed a staff member within the medication room. The Compliance Officer observed the staff member exit the medication room and did not lock the room upon exiting. The Compliance Officer observed multiple insulin syringes unlocked in a miniature refrigerator:

3. In an interview, E1 and E2 reported the medication refrigerator and medication room should have been locked, and E1 and E2 acknowledged medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.