GEMS ASSISTED LIVING #4

<p>Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently and the Department was provided false or misleading information.</p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed this statute went into effect on October 1, 2021. The review further revealed a Plan of Correction (POC) for this deficiency from the complaint and compliance inspection conducted on February 7, 2024. The POC indicated this deficiency was corrected on March 20, 2024. The POC stated, “All staff received a copy of our fall prevention and recovery policy and procedure, during all staff meeting March 20, 2024, training was conducted by [facility personnel]...Upon new hire, all staff will be given the fall prevention and recovery p/p to review and sign. All staff will also have annual fall prevention and recovery training during designated monthly Inservice.”</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Fall Recovery” dated January 10, 2024. The P&P stated: "This facility shall develop an <u>initial training</u>, <u>conduct</u>, and <u>administer continued competency Training</u> [underline in original] in Fall Prevention and Fall Recovery Program every 6 months.”</p><p><br></p><p><br></p><p>3. A review of E1's personnel record revealed E1 was hired as the manager in 2023. The review revealed E1 received training regarding fall prevention and fall recovery on May 17, 2023. However, the review revealed no such training before or after May 17, 2023.</p><p><br></p><p><br></p><p>4. In an interview, E1 reported E1 received training regarding fall prevention and fall recovery in 2024. However, E1 did not provide documentation of the training in 2024. When the Compliance Officer asked how often the training was provided, E1 stated, “We do it every year.”</p><p><br></p><p><br></p><p>5. A review of E4’s personnel record revealed E4 was hired as a housekeeper. The review revealed E4 received training regarding fall prevention and fall recovery on March 20, 2024, December 20, 2024, and March 20, 2025. However, the review revealed E4 did not receive training regarding fall prevention and fall recovery every six months as required per P&P.</p><p><br></p><p><br></p><p>6. In an interview, E3 stated E5 was "sometimes used to transport residents.” E6 reported E5 starting transporting residents several weeks before the date of the inspection.</p><p><br></p><p><br></p><p>7. A review of facility documentation revealed a personnel schedule which indicated E5 worked several shifts during the first week of December 2024, contrary to E3’s statement.</p><p><br></p><p><br></p><p>8. A review of E5’s personnel record revealed E5 worked as a driver. The review revealed E5 received training regarding fall prevention and fall recovery on December 20, 2024, several weeks after working.</p><p><br></p><p><br></p><p>9. A review of E6’s personnel record revealed E6 was hired as a caregiver before this rule went into effect. The review revealed no documentation demonstrating E6 received training regarding fall prevention and fall recovery in at least a 12 month period before the date of the inspection.</p><p><br></p><p><br></p><p>10. A review of E7’s personnel record revealed E7 was hired as a caregiver in 2022. The review revealed E7 received training regarding fall prevention and fall recovery on December 20, 2024. However, the review revealed no such training within six months before December 20, 2024, as required per P&P.</p><p><br></p><p><br></p><p>11. A review of E8's personnel record revealed E8 was hired as a caregiver. The review revealed several hire dates for E8, ranging from 2015 to 2024. The review revealed E8 received training regarding fall prevention and fall recovery on December 20, 2024. However, the review revealed no such training within six months before December 20, 2024, as required per P&P.</p><p><br></p><p><br></p><p>12. A review of E9's personnel record revealed E9 was hired as a caregiver. The review revealed E9 first received training regarding fall prevention and fall recovery on December 20, 2024, several months after E9’s starting date of employment. However, the review revealed no such training initially upon hire.</p><p><br></p><p><br></p><p>13. A review of E10's personnel record revealed E10 was hired as a housekeeper. The review revealed E10 first received training regarding fall prevention and fall recovery on March 20, 2025, several months after E10’s starting date of employment. However, the review revealed no such training initially upon hire.</p><p><br></p><p><br></p><p>14. In an interview, E1 acknowledged facility personnel failed to administer a training program for all staff regarding fall prevention and fall recovery initially and every six months as required by P&P.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint and compliance inspection conducted on February 7, 2024, and the compliance inspection conducted on February 9, 2022.</p>

<p>Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of tuberculosis, for six of nine sampled personnel members. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed this rule went into effect on May 4, 2022.</p><p><br></p><p><br></p><p>2. A review of E1's personnel record revealed E1 was hired as the manager after this rule went into effect. However, the review revealed no documentation demonstrating E1 received training and education related to recognizing the signs and symptoms of TB upon hire and annually thereafter.</p><p><br></p><p><br></p><p>3. A review of E4's personnel record revealed E4 was hired as a housekeeper after this rule went into effect. However, the review revealed no documentation demonstrating E4 received training and education related to recognizing the signs and symptoms of TB upon hire and annually thereafter.</p><p><br></p><p><br></p><p>4. In an interview, E3 stated E5 was "sometimes used to transport residents.” E6 reported E5 starting transporting residents several weeks before the date of the inspection.</p><p><br></p><p><br></p><p>5. A review of facility documentation revealed a personnel schedule which indicated E5 worked several shifts during the first week of December 2024, contrary to E3’s statement.</p><p><br></p><p><br></p><p>6. A review of E5’s personnel record revealed E5 worked as a driver. However, the review revealed no documentation demonstrating E5 received training and education related to recognizing the signs and symptoms of TB upon hire.</p><p><br></p><p><br></p><p>7. A review of E6's personnel record revealed E6 was hired as a caregiver before this rule went into effect. However, the review revealed no documentation demonstrating E6 received training and education related to recognizing the signs and symptoms of TB when the rule went into effect and annually thereafter.</p><p><br></p><p><br></p><p>8. A review of E9's personnel record revealed E9 was hired as a caregiver after this rule went into effect. However, the review revealed no documentation demonstrating E9 received training and education related to recognizing the signs and symptoms of TB upon hire.</p><p><br></p><p><br></p><p>9. A review of E10's personnel record revealed E10 was hired as a housekeeper after this rule went into effect. However, the review revealed no documentation demonstrating E10 received training and education related to recognizing the signs and symptoms of TB upon hire.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspection conducted on April 8, 2024.</p>

<p>Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A) and (C), for five of nine sampled personnel members. The deficient practice posed a risk if the employees were a danger to a vulnerable population.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A.R.S. § 36-411(A) states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work."</p><p><br></p><p><br></p><p>2. A.R.S. § 36-411(C)(2) and (4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person's fingerprint clearance card… 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.”</p><p><br></p><p><br></p><p>3. A review of facility documentation revealed a policy and procedure (P&P) titled "FINGERPRINT" dated January 10, 2024. The P&P stated: "Owner or Manager of this assisted living facility must require prospective employee to obtain fingerprint clearance, and must make efforts to verify with the Department of Public Safety (DPS) the status of prospective employee’s fingerprint clearance card…The Manager shall obtain documentation of fingerprint clearance for every individual employee or volunteer who works in the facility…The fingerprint card must be current and valid…The timeframe for renewal of Fingerprint shall be monitored."</p><p><br></p><p><br></p><p>4. A review of E1's personnel record revealed E1 was hired as the manager. The review revealed a photocopy of E1’s fingerprint clearance card (FCC) with the card number and expiration date circled in pen. However, the review revealed the FCC expired on October 18, 2024. The review revealed a printout from the DPS website which indicated E1 applied for a second FCC on November 7, 2024, after E1’s previous FCC expired. The review further revealed a photocopy of a second FCC, dated as issued on January 6, 2025, more than two months after E1’s previous FCC expired</p><p><br></p><p><br></p><p>5. A review of the DPS website confirmed E1's first FCC expired on October 18, 2024; E1 reapplied on November 7, 2024; and E1’s current FCC was issued on January 6, 2025, and was valid.</p><p><br></p><p><br></p><p>6. In an interview, E1 acknowledged E1’s FCC had been expired for more than two months.</p><p><br></p><p><br></p><p>7. A review of E4’s personnel records revealed E4 was hired as a housekeeper. The review revealed a note which stated E4 “Needs Fingerprint card [and] verification.” The review revealed E4’s current FCC and a printout from the DPS website. However, the printout revealed facility personnel did not verify E4’s FCC until August 24, 2024, more than one year after E4’s starting date of employment. The review further revealed no documentation demonstrating facility personnel made documented, good faith efforts to verify that E4 was not on the adult protective services (APS) registry.</p><p><br></p><p><br></p><p>8. A review of the APS registry website revealed E4 was not on the registry.</p><p><br></p><p><br></p><p>9. In an interview, E3 stated E5 was "sometimes used to transport residents.” E6 reported E5 starting transporting residents several weeks before the date of the inspection. E6 reported E5 had worked for an in-home caregiving company owned by the same individual as this facility and had not needed a FCC for that job. E6 reported E5 was in the process of getting a FCC.</p><p><br></p><p><br></p><p>10. A review of facility documentation revealed a personnel schedule which indicated E5 worked several shifts in December 2024, contrary to E3’s statement.</p><p><br></p><p><br></p><p>11. A review of E5’s personnel record revealed E5 worked as a driver. The review revealed an undated and unsigned application for a FCC with an incomplete application number (i.e. missing the last digit). The review revealed a form containing prints of E5’s fingerprints dated March 10, 2021. However, the review revealed no current FCC or documentation demonstrating facility personnel made documented, good faith efforts to verify the status of E5’s FCC. The review further revealed no documentation demonstrating facility personnel made documented, good faith efforts to verify that E5 was not on the APS registry.</p><p><br></p><p><br></p><p>12. A review of the DPS website revealed E5 first applied for a FCC on January 6, 2020, but was denied on February 14, 2020. Upon testing all potential application numbers, the website revealed E5 did not submit the aforementioned application. The website confirmed E5 did not have a FCC.</p><p><br></p><p><br></p><p>13. A review of the APS registry website revealed E5 was not on the registry.</p><p><br></p><p><br></p><p>14. A review of E7's personnel record revealed E7 was hired as a caregiver in 2022. The review revealed a photocopy of E7’s FCC, dated as expired on January 5, 2023, and a printout from the DPS website which indicated E7 applied for a second FCC on January 19, 2023. However, the printout stated DPS was “Waiting On Applicant Fingerprints.” The review revealed another printout from the DPS website, dated May 19, 2023, which stated DPS was still “Waiting On Applicant Fingerprints.” The review revealed a receipt for fingerprinting services dated May 22, 2023, and a form containing prints of E7’s fingerprints. The form included a handwritten note which stated “Had to Redo prints [as] the last ones mailed in where [<em>sic</em>] not ledgable [<em>sic</em>]. The review revealed a checklist dated 2024 which indicated E7’s FCC was needed. The review revealed facility personnel did not verify E7’s FCC upon hire. The review further revealed no current valid FCC for E7.</p><p><br></p><p><br></p><p>15. A review of the DPS website revealed E7's first FCC expired on January 5, 2023, and E7 reapplied on February 13, 2025. The website further revealed E7’s current FCC was issued on February 21, 2025, (after E7’s ending date of employment) and was valid.</p><p><br></p><p><br></p><p>16. A review of E8's personnel record revealed E8 was hired as a caregiver. The review revealed several hire dates for E8, ranging from 2015 to 2024. The review revealed a printout from the DPS website dated June 6, 2022. The printout revealed E8 applied for a FCC on July 31, 2013. However, the printout stated E8’s FCC was “Not Valid.” The review revealed E8 was most recently hired in 2024 and facility personnel did not verify E8’s FCC upon E8’s most recent hire date. The review further revealed E8 did not have a valid FCC for the entirety of each of E8’s documented terms of employment at this facility.</p><p><br></p><p><br></p><p>17. A review of the DPS website revealed the following:</p><p><br></p><p>- E8's first FCC expired on May 25, 2013;</p><p><br></p><p>- E8 reapplied on July 31, 2013, and the “Current Status” of the application/FCC was “Invalid;”</p><p><br></p><p>- E8 reapplied for a second time on October 16, 2018, and the “Current Status” of the application/FCC was “Invalid;” and</p><p><br></p><p>- E8 reapplied for a third time on February 23, 2023, and the “Current Status” of the application/FCC was “Application Complete - Results mailed to applicant.”</p><p><br></p><p><br></p><p>18. A review of Department documentation revealed a letter from a representative of the Fingerprint Program at the Arizona Department of Health Services Bureau of Special Licensing dated April 22, 2019. The review revealed the letter was sent to AL11108 Gems Assisted Living LLC (a facility owned by the same owner as this facility). The letter stated: “You are hereby notified that a Fingerprint Clearance Card for [E8] was SUSPENDED by the Arizona Department of Public Safety. You must notify your respective ADHS licensing bureau within 14 calendar days confirming the above individual has either: 1. Been suspended or terminated to prevent [E8] from having contact with persons receiving services from your agency; or 2. If eligible, petitioned the Arizona Board of Fingerprinting for a Good Cause Exception; and, provided your agency with a copy of [E8’s] complete application for a Good Cause Exception.” The review revealed a second letter from a representative of the Fingerprint Program at the Arizona Department of Health Services Bureau of Special Licensing, dated March 22, 2023. The review revealed the letter was sent to a representative of this facility. The letter stated: “You are hereby notified that a Fingerprint Clearance Card for [E8] was DENIED by the Arizona Department of Public Safety. You must notify your respective ADHS licensing bureau within 14 calendar days confirming the above individual has either: 1. Been suspended or terminated to prevent [E8] from having contact with persons receiving services from your agency; or 2. If eligible, petitioned the Arizona Board of Fingerprinting for a Good Cause Exception; and, provided your agency with a copy of [E8’s] complete application for a Good Cause Exception.” The review further revealed facility personnel made no such notifications to ADHS.</p><p><br></p><p><br></p><p>19. In an interview, E1 acknowledged the facility was not in compliance with this rule.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a manager or a caregiver provided current documentation of first aid and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for two of nine applicable sampled personnel members. The deficient practice posed a risk if a manager or a caregiver was unable to meet a resident's needs during an emergency.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a policy and procedure (P&P) titled "CPR AND FIRST AID” dated January 10, 2024. The P&P stated: "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and that their certification is maintained and [is] current as long as they are employed by this facility.”</p><p><br></p><p><br></p><p>2. A review of E1's personnel record revealed E1 was hired as the manager in 2023. The review revealed a first aid and CPR certification dated as expired on April 23, 2024. The review further revealed a current first aid and CPR certification dated as issued on December 5, 2024, more than seven months after E1’s previous certification expired.</p><p><br></p><p><br></p><p>3. In an interview, E2 confirmed E1 did not have first aid and CPR certification between April 24, 2024, and December 4, 2024.</p><p><br></p><p><br></p><p>4. A review of E7's personnel record revealed E7 was hired as a caregiver in 2022. The review revealed a CPR certification dated as expired in June 2023 and a first aid and CPR certification dated as issued on January 31, 2024. However, the review revealed no CPR certification between July 1, 2023, and January 30, 2024, approximately seven months after E7’s previous certification expired. The review further revealed no first aid certification before January 31, 2024.</p><p><br></p><p><br></p><p>5. In an interview, when the Compliance Officer requested E5’s first aid certification before January 31, 2024, E2 stated, “I didn’t find anything.”</p><p>E2 acknowledged that E1, E5, and E7 had provided <span style="background-color: rgb(255, 255, 255); color: rgb(68, 68, 68);">assisted living services to residents without a valid CPR certification.</span></p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services, for one of four sampled caregivers. The deficient practice posed a risk if a caregiver did not have the skills and knowledge necessary to meet a resident's needs and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on April 8, 2024. The POC indicated this deficiency was corrected on April 15, 2024. The POC stated: “To address this deficiency the HR Manager will lead oversight and take the following actions: Verify the caregiver has completed a skills assessment before a new caregiver can be scheduled to work…HR Manager will conduct a bi-annual audit of employee files to ensure skills assessment are completed and in every employee file.”</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled “STAFFING and RECORDKEEPING” dated January 10, 2024. The P&P stated: “Each employee hired by this facility must have the following on Employee’s file…5. Verification of skills and Knowledge.” The review revealed a P&P titled “APPLICANT AND EMPLOYEE REQUIREMENT” dated January 10, 2024. The P&P stated: “Upon being hired by the facility the applicant must [have]...Verification of qualifications, knowledge, and skills to perform the duties of the job hired for.” The review further revealed a series of personnel schedules dated between June 2024 and April 2025 which revealed E9 worked on a regular basis.</p><p><br></p><p><br></p><p>3. A review of E9's personnel record revealed E9 was hired as a caregiver. However, the review revealed no documentation demonstrating the manager ensured E9's skills and knowledge were verified and documented before E9 provided physical health services.</p><p><br></p><p><br></p><p>4. In an interview, when the Compliance Officer asked if E9 had documented verification of E9’s skills and knowledge, E3 stated, “I’m not sure.” After searching for the verification, E3 stated, “I don’t see a checklist in here.”</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint inspection conducted on April 8, 2024.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided evidence of freedom from infectious tuberculosis (TB) on or before the date the caregiver began providing services at or on behalf of the assisted living facility as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of four sampled caregivers. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of…iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)."</p><p><br></p><p><br></p><p>2. R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)."</p><p><br></p><p><br></p><p>3. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel."</p><p><br></p><p><br></p><p>4. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (“TB”) TESTING” dated January 10, 2024. The P&P stated: “1. All individuals including residents of this facility will be screened for infectious tuberculosis…a. All employees and residents of this facility are required to provide one of the following on admission or starting employment <strong>Baseline screening</strong> [bold in original] that includes…iii. Obtaining documentation of the individual's freedom from infectious tuberculosis…b. Documentation of a negative Mantoux skin test or other tuberculosis screening testwithin [<em>sic</em>] 12 months of the date of employment or residence in the facility…6. The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as an employee, providing services to residents, or moving into the facility…8. All documentations shall be maintained for tuberculosis <u>risk assessment</u> [underline in original], tuberculosis screening test, signs or symptoms of an employee/volunteer and residents.”</p><p><br></p><p><br></p><p>5. A review of E9's personnel record revealed E9 was hired as a caregiver. The review revealed a negative TST dated as read June 2, 2024, and a second negative TST, dated as read on July 12, 2024. However, the second TST was dated as read after the date E9 began providing services at or on behalf of the assisted living facility.</p><p><br></p><p><br></p><p>6. A review of facility documentation revealed a series of personnel schedules dated June-July 2024 which revealed E9 worked before E9’s second TST was read.</p><p><br></p><p><br></p><p>7. In an interview, E1 acknowledged E9 began providing services before providing evidence of freedom from TB.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspection conducted on April 8, 2024.</p>

<p>Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for two of two sampled residents. The deficient practice posed a potential TB exposure risk to residents.</p><p><br></p><p><br></p><p>Findings include: </p><p><br></p><p><br></p><p>1. R9-10-113(A)(2)(a)(i-iii) states: "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)."</p><p><br></p><p><br></p><p>2. A review of facility documentation revealed a policy and procedure (P&P) titled “TUBERCULOSIS (“TB”) TESTING” dated January 10, 2024. The P&P stated: “1. All individuals including residents of this facility will be screened for infectious tuberculosis…a. All employees and residents of this facility are required to provide one of the following on admission or starting employment <strong>Baseline screening</strong> [bold in original] that includes: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, [and] iii. Obtaining documentation of the individual's freedom from infectious tuberculosis…b. Documentation of a negative Mantoux skin test or other tuberculosis screening testwithin [<em>sic</em>] 12 months of the date of employment or residence in the facility…6. The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as an employee, providing services to residents, or moving into the facility…8. All documentations shall be maintained for tuberculosis <u>risk assessment</u> [underline in original], tuberculosis screening test, signs or symptoms of an employee/volunteer and residents.”</p><p><br></p><p><br></p><p>3. A review of R1's medical record revealed R1 was admitted more than seven days before the date of the inspection. The review revealed no documentation assessing risks of prior exposure to infectious TB. The review revealed a document titled “PHYSICIANS ADMISSION ORDERS” which indicated R1 did not receive a skin test or a blood test, but received a chest x-ray instead. The review further revealed an x-ray report which did not state R1 had a history of TB or documentation of latent TB infection, nor did the report state R1 was free from infectious TB.</p><p><br></p><p><br></p><p>4. A review of R2's medical record revealed R2 was admitted more than seven days before the date of the inspection. However, the review revealed no documentation assessing risks of prior exposure to infectious TB or determining if R2 had signs or symptoms of TB.</p><p><br></p><p><br></p><p>5. In an interview, E3 reported E3 did not know residents needed the risk assessment and signs and symptoms screening.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspection conducted on April 8, 2024.</p>

<p>Based on record review and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility that included terms of occupancy, including the date of occupancy or expected date of occupancy, for one of two sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed a residency agreement. However, the residency agreement did not include R2's date of occupancy or expected date of occupancy.</p><p><br></p><p><br></p><p>2. In an interview, E1 acknowledged R2's residency agreement did not include R2's date of occupancy or expected date of occupancy.</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspection conducted on April 8, 2024.</p>

<p>Based on record review and interview, the manager failed to ensure a resident's written service plan included the frequency of assisted living services being provided to the resident, for two of two sampled residents.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R1's medical record revealed two service plans dated October 7, 2024, and January 7, 2025, respectively and a third, undated service plan. All three service plans indicated R1 was to receive incontinence care. However, the three service plans did not include the frequency of incontinence care. The service plan dated October 7, 2024, indicated R1 was to receive assistance bathing. However, the service plan did not include the frequency of bathing.</p><p><br></p><p><br></p><p>2. A review of R2's medical record revealed service plans dated October 7, 2024; January 7, 2025; and April 7, 2025. All three service plans indicated R2 was to receive incontinence care and assistance with transferring. However, the service plans did not include the frequency of either service.</p><p><br></p><p><br></p><p>3. In an interview, E1 stated, “Any service we provide [residents] should have a frequency attached to it.”</p><p><br></p><p><br></p><p>Technical assistance was provided on this rule during the complaint inspection conducted on April 8, 2024.</p>

<p>Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two sampled residents. The deficient practice posed a risk as services could not be verified as provided against a service plan.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of R2's medical record revealed service plans dated January 7, 2025, and April 7, 2025. Both service plans indicated facility personnel were to provide assistance with dressing two times per day. The review further revealed documentation of assisted living services provided to R2 (ADLs) dated April 2025. However, the ADLs revealed no documentation of assistance with dressing.</p><p><br></p><p><br></p><p>2. In an interview, when the Compliance Officer asked where facility personnel documented assisting R2 with dressing, E3 stated, “We don’t.” E1 reported caregivers assisted R2 with dressing but did not document it.</p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did 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. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility and the Department was provided false or misleading information.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of Department documentation revealed the facility was authorized to provide directed care services. The review further revealed a Plan of Correction (POC) for this deficiency from the complaint inspection conducted on April 8, 2024. The POC indicated this deficiency was corrected on April 15, 2024. The POC stated, “Upon survey completion, alarms have been activated at all exit points.”</p><p><br></p><p><br></p><p>2. During an environmental inspection of the facility, the Compliance Officer observed a door leading from an unlocked office area to a covered corridor between the two buildings of the facility. The Compliance Officer observed the door did not have a control or an alert installed. Upon opening the door, the Compliance Officer heard no alert. Upon exiting the office area through the door, the Compliance Officer observed a metal screen door leading to the street with no control or alert installed. Upon opening this second door, the Compliance Officer heard no alert.</p><p><br></p><p><br></p><p>3. In an interview, E1 reported residents and facility staff never used the door leading from the unlocked office to the covered corridor.</p><p><br></p><p><br></p><p>This is a repeat citation from the complaint inspection conducted on April 8, 2024.</p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure policies and procedures (P&Ps) were implemented for inventorying controlled substances. The deficient practice posed a risk as the standards expected of employees to ensure resident safety were not followed.</p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p>1. A review of facility documentation revealed a P&P titled "STORING, INVENTORYING AND DISPENSING OF CONTROLLED MEDICATIONS," dated January 10, 20234. The P&P stated: “ Medication containers for all narcotic or controlled medications must be marked with a ‘C’ on the label to indicate that the medication is a ‘controlled substance.’ These medications are differentiated in this manner as special procedures must be followed for controlled substances. 2. For every medication marked with a ‘C’, a Narcotic Inventory Sheet should be maintained… 5. When assisting a resident in taking a controlled medication, a staff member should: Count the number of tablets/capsules available (e.g., in a bubble-packed card) and enter that number in the ‘Amount on Hand’ column on the form. Draw a line through the ‘Amount Received’ column. Write the number of tablets/capsules to be given at the designated time in the ‘Amount Given’ column. Subtract the number of tablets/ capsules written in the ‘Amount Given’ column from the number in the ‘Amount on Hand’ column. Write the resulting number in the ‘Amount Remaining’ column (this should be the number of tablets/capsules left after the current dose is taken).”</p><p><br></p><p><br></p><p>2. The Compliance Officer observed controlled medications for R2, R5, R9, and R10. However, none of the controlled medications were marked with a ‘C’ as required per P&P.</p><p><br></p><p><br></p><p>3. In an interview, E1, E2, and E3 acknowledged the controlled medications were not marked per P&P.</p><p><br></p><p><br></p><p>4. The Compliance Officer observed facility personnel mark each of the medication containers.</p><p><br></p><p><br></p><p>5. A review of facility documentation revealed a narcotics count binder. The review revealed a "Controlled Medication Record" document for each of the observed controlled medications for R2, R5, R9, and R10. However, the documents did not contain columns for the “Amount on Hand” as required per P&P.</p><p><br></p><p><br></p><p>6. In an interview, E1, E2, and E3 acknowledged facility personnel did not implement the P&P.</p>

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services and according to policies and procedures, for three of five sampled caregivers or assistant caregivers. The deficient practice posed a risk if a caregiver or assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure (P&P) titled "Documentation of training in Skills and Knowledge" which stated, "The hiring manager is responsible for observing the skills and acknowledgement of completion and signing off checklist on the day or orientation or before new employee is scheduled a shift."

2. A review of the personnel records of E4, E5, E6, E7, and E8 revealed completed "CAREGIVER SKILLS and KNOWLEDGE DOCUMENTATION" forms for E7 and E8, but not for E4, E5, and E6.

3. In an interview, E1 reported the manager verified the skills and knowledge of E4, E5, and E6. However, E1 acknowledged such documentation was not available for review.

Based on observation and interview, the manager failed to ensure a means of exiting the facility for a resident who did 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. The deficient practice posed a risk if the facility was unaware of the egress of a resident from the facility.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. During the environmental inspection of the facility, the Compliance Officer observed the front door of the main building did not have a control installed but did have an alert installed. However, the alert was set to the "OFF" position and did not sound when the Compliance Officer opened the door. The Compliance Officer observed the sliding glass door leading from the kitchen of the main building to the back yard did not have a control or an alert installed. The Compliance Officer observed the sliding glass door leading from the foyer of the secondary building to the back yard did not have a control installed but did have an alert installed. However, the alert was set to the "OFF" position and did not sound when the Compliance Officer opened the door. The Compliance Officer observed the door leading from the kitchen of the secondary building to the front yard did not have a control or an alert installed.

3. In an interview, E1 stated the alert on the front door was "probably turned off" and the alert on the sliding glass door of the main building "fell off."

Based on documentation review and interview, the manager failed to ensure policies and procedures for medication services included procedures for assisting a resident in procuring medication. The deficient practice posed a risk if required medication was not available for a resident.

Findings include:

1. A review of facility documentation revealed no policy and procedure including procedures for assisting a resident in procuring medication.

2. In an interview, when the Compliance Officer asked for assistance in finding the policy and procedure for this rule, E2 stated, "I don't see anything."

Based on record review, interview, and documentation review, the manager failed to ensure medication administered to a resident was administered in compliance with a medication order, for two of three sampled residents. The deficient practice posed a risk if a resident experienced a change in condition due to improper administration of medication.

Findings include:

1. A review of R1's medical record revealed a current service plan which indicated R1 required medication administration services. The review revealed a medication order for "Haloperidol 2 mg (milligrams) [one tab] at bedtime" dated June 12, 2023. The review further revealed a medication administration record (MAR) dated March 2024. The MAR revealed R1 did not receive R1's "Haloperidol" on March 16-19, 2023. The MAR indicated the "Haloperidol" was "Not given" because it was "out of stock" on March 17-18, 2024. The MAR included no notes for March 16 and 19, 2024.

2. In an interview, E1 stated "[R1] was out of [R1's] haloperidol for four days."

3. A review of R2's medical record revealed a current service plan which indicated R2 required medication administration services. The review revealed a medication order for "hydroCHLOROthiazide Tablet, 12.5 MG, 1 tablet in the morning, Orally, Once a day, 30 days" dated December 7, 2023. The review revealed a MAR dated December 2023 which revealed R2 did not receive R2's "hydroCHLOROthiazide" until December 11, 2023. The review further revealed a MAR dated March 2024 which revealed R2 did not receive R2's morning medications on December 19, 2024, which included R2's "hydroCHLOROthiazide" and other medications.

4. A review of facility documentation revealed a "Medication Incident Report" dated December 11, 2023. The incident report stated, "[PCP] came to see [R2] on 12/6/23 due to [medical issue]. [PCP] prescribed a water pill, it was delivered 12/8/23 between 2pm & 6pm. Somehow it ended up in the microwave and was not given from 12/8/23 to 12/10/23. It was given when found on 12/11/23."

5. In an interview, E1 acknowledged the aforementioned medications were not administered as ordered. E1 reported E4 was working the medication cart on March 19, 2024, when R2's morning medication was not given. E1 reported E4 was called away to take a resident to an appointment and did not administer R2's medication or communicate to other caregivers that E4 did not administer the medication.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to cover receiving, storing, inventorying, tracking, and dispensing medication.

Findings include:

1. A review of facility documentation revealed a policy and procedure (P&P) titled "MEDICATIONS SERVICES," dated April 12, 2022. The P&P stated, "All...medications brought to the facility will be received by the caregiver on duty. Medications will be locked in the medication storage area." However, the P&P did not cover inventorying, tracking, and dispensing medication. The review revealed a "Medication Incident Report" dated December 11, 2023. The incident report stated, "[PCP] came to see [R2] on 12/6/23 due to [medical issue]. [PCP] prescribed a water pill, it was delivered 12/8/23 between 2pm & 6pm. Somehow it ended up in the microwave and was not given from 12/8/23 to 12/10/23. It was given when found on 12/11/23." The review revealed the medication was not "received by the caregiver on duty" and "locked in the medication storage area" as required by P&Ps.

2. In an interview, E1 acknowledged the facility did not implement P&Ps covering receiving and storing medication. E1 stated the P&Ps covering inventorying, tracking, and dispensing medication were "at every house but this one."

Based on documentation review, record review, and interview, the health care institution failed to administer a training program regarding fall prevention and fall recovery training to include initial training and continued competency, for two of five personnel members sampled. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention and Fall Recovery" dated March 2023. The policy and procedure stated " ...This facility shall develop an initial training, conduct and administer continued competency training in Fall Prevention and Fall Recovery Program every 12 months..."

2. A review of E3's (hired as a caregiver) and E5's (hired as a caregiver) personnel records revealed initial training and continued competency training in fall prevention and fall recovery were not available for review.

3. In an interview, E1 reported E2 and E5 had not completed initial training because they were hired after the in-service training was provided to all other staff.

4. In an interview, E1 acknowledged initial training and continued competency training in fall prevention and fall recovery for E3 and E5 was not available for review.

This is a repeat deficiency from the compliance inspection conducted on February 9, 2022.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1), for one of five employees sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C)(1) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency."

2. A review of E2's personnel record revealed E2 had a valid fingerprint clearance card. However, documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) was not available for review.

3. In an interview, E1 acknowledged documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) for E2 was not available for review.