NEW BEGINNINGS IN PHOENIX, LLC

Based on observation, record review, documentation 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 (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services.

Findings include:

1. The Compliance Officer observed E2 working with residents on-site during the inspection.

2. A review of E2's personnel record revealed no documentation of completion of a caregiver training program approved by the Department or the NCIA Board.

3. In an interview, E1 reported E2 was a volunteer caregiver with a certified nursing assistant (CNA) license.

4. A review of the Arizona State Board of Nursing website revealed E2's CNA license was inactive.

5. In an interview, E2 confirmed E2 worked at the facility as a caregiver.

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount, type and frequency of assisted living services to be provided to the resident, for one of two sampled residents. The deficient practice posed a risk if a resident did not receive sufficient services as necessary.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 9, 2023 for personal care services. The service plan indicated R1 required assistance with toileting and oral care. However, the service plan did not indicate the amount or frequency at which the services would be provided.

2. In an interview, E1 reviewed R1's service plan and acknowledged R1's service plan did not reflect the amount or frequency of oral care or toileting provided to R1.

This is a repeat citation from the previous compliance inspection conducted on November 14, 2022.

Based on record review and interview, the manager failed to ensure a 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.

Findings include:

1. A review of R1's medical record revealed a service plan dated November 9, 2023 for personal care services. The service plan indicated R1 required assistance with toileting and oral care. However, the service plan did not indicate the amount or frequency at which the services would be provided.

2. A review of R1's medical record revealed a document titled "Assisted Living Facility Daily Activity Record (ADL)" dated November-December 2023. However, the ADL document did not reflect R1 was provided oral care or toileting.

3. In an interview, E1 reviewed R1's ADL document and acknowledged the document did not reflect R1 was provided oral care or toileting.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area inaccessible to residents. The deficient practice posed a risk to residents who were not prescribed the accessible medication.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed a cabinet in the dining area. The cabinet contained various medications belonging to residents. There was a lock on the cabinet, however the lock was broken, making the medication accessible.

2. In an interview, E1 acknowledged the medication was not stored in a locked location.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan.

Findings include:

1. A review of facility documentation revealed the most recent disaster drill was conducted on July 10, 2023. There was no additional documentation indicating a disaster drill was conducted at least once every three months.

2. In an interview, E1 acknowledged a disaster drill was not conducted at least every three months.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area 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 the environmental inspection of the facility, the Compliance Officer an unlocked cabinet under the kitchen sink. The cabinet contained a can of "WD-40" and a bottle of dish detergent.

2. In an interview, E1 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked area inaccessible to residents.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience, for a caregiver or assistant caregiver.

Findings include:

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

2. In an interview, E1 reviewed the policies and procedures and acknowledged the policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was missing and was unavailable for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented covering the provision of assisted living services, including coordinating the provision of assisted living services.

Findings include:

1. A review of the facility's policies and procedures revealed there was no policy covering the provision of assisted living services, including coordinating the provision of assisted living services.

2. In an interview, E1 reviewed the policies and procedures and acknowledged the policy and procedure covering the provision of assisted living services, including coordinating the provision of assisted living services, was missing and was unavailable for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented covering the provision of assisted living services, including making vaccination for influenza and pneumonia available to residents according to Arizona Revised Statutes (A.R.S.) \'a7 36-406(1)(d).

Findings include:

1. A review of the facility's policies and procedures revealed there was no policy covering making vaccination for influenza and pneumonia available to residents according to A.R.S. \'a7 36-406(1)(d).

2. In an interview, E1 reviewed the policies and procedures and acknowledged the policy and procedure covering the provision of assisted living services, including making vaccination for influenza and pneumonia available to residents according to A.R.S. \'a7 36-406(1)(d), was missing and was not available for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented covering the provision of assisted living services, including obtaining resident preferences for food.

Findings include:

1. A review of the facility's policies and procedures revealed there was no policy covering the provision of assisted living services, including obtaining resident preferences for food.

2. In an interview, E1 reviewed the policies and procedures and acknowledged the policy and procedure covering the provision of assisted living services, including obtaining resident preferences for food, was missing and was unavailable for review.