BELLA VITA RESIDENTIAL ASSISTED LIVING LLC

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 organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of the facility's policies and procedures titled, "Employees and Volunteers Orientation and On-going Training Policy and Procedures," revealed in section three, "... On-going training may include, but is not limited to: h. Trip and fall preventions". However there is no mention of fall recovery.

2. A review of E2's personnel record revealed no documentation of fall prevention and fall recovery training.

3. In an interview, E1 acknowledged documentation was not available that showed E2 completed fall prevention and fall recovery training.

This is a repeat deficiency from the compliance inspection conducted November 30, 2022.

Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to residents who were unable to self-administer medications.

Findings include:

1. The Compliance Officer observed the medicine closet unlocked and slightly open. The Compliance Officer was able to open the door without the assistance of a key. The sample of medications located within the closet were as follows:
- Acetaminophen PM 25-500 mg
- Acetamin 500 mg
- Senna-Plus Tab 8.6-50 mg
- 90 Tab Acetamin PM 25-500 mg

2. The Compliance Officer observed 1ml Aplisol and Gabapentin Sol 250/5 ml unlocked in the refrigerator that was located by the kitchen.

3. In an interview, E1 acknowledged medications were stored unlocked.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of the residents.

Findings include:

1. The Compliance Officer observed the following poisonous or toxic materials stored in an unlocked laundry room located in the backyard of the facility.
- A bottle of Fabuloso Multi-Purpose Cleaner
- A bottle of Bleach
- A container of Lysol Disinfecting Wipes
- A 166.5 Fl OZ container of Arm & Hammer plus Oxiclean stain fighters

2. In an interview, E1 acknowledged there were poisonous or toxic materials stored by the assisted living facility maintained in unlocked areas.

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

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled " Employees and Volunteers Orientation and On-going Training Policy and Procedures" dated September 2, 2020. The policy stated "...3. On-going training may include, but is not limited to, at least 10 hours of one or more of the topics listed below after the first year of employment...h. Trip and fall preventions" However, the policy did not include initial training and continued competency training in fall prevention and fall recovery.

2. A review of E1's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

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

4. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

5. In an interview, E1 reported to be unaware of the requirement. E1 acknowledged the facility had not developed and 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 as the licensee did not provide the following for review: E2's and E3's qualifications, including skills and knowledge, applicable to E2's and E3's job duties; E2's and E3's completed orientation; E2's CPR and first aid training; E1's complete personnel record; R1's and R2's documentation of orientation to the exits, and a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of E2's (hired as a caregiver) personnel record revealed the record did not include evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties.

2. A review of E3's (hired as a caregiver) personnel record revealed the record did not include evidence of E3's qualifications, including skills and knowledge applicable to E2's job duties.

3. A review of E2's (hired as a caregiver) personnel record revealed the record did not include documentation of E2's completed orientation.

4. A review of E3's (hired as a caregiver) personnel record revealed the record did not include documentation of E3's completed orientation.

5. A review of E2's (hired as a caregiver in 2022) personnel record revealed the record did not include evidence to indicate E2 completed CPR or first aid training.

6. The Compliance Officer requested to review E1's (hired as a manager) personnel record. E1 faxed E1's personnel record to the facility and the Compliance Officer reviewed the following:
-An employment application with E1s name, date of birth, and contact telephone number;
-E1's starting date of employment;
-E1's education and experience applicable to E1's job duties; and
-Compliance with the requirements in A.R.S. \'a7 36-411(C)
However, the additional faxed pages were blank, the printer appeared to be out of ink, and documentation of
E1's qualifications, including skills and knowledge applicable to E1's job duties, E1's completed orientation and in-service education required by policies and procedures, evidence of freedom from infectious tuberculosis, cardiopulmonary resuscitation training (CPR) and first aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) was not available for review.

7. A review of R1's medical record revealed the record did not include documentation indicating the resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R1's acceptance by the facility.

8. A review of R2's medical record revealed the record did not include documentation indicating the resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after R2's acceptance by the facility.

9. A review of E1's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

10. A review of E2's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

11. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

12. 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, documentation review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for two of three personnel records sampled. The deficient practice posed a risk if E2 and E3 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel records did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

R9-10-806.A.4. A manager shall ensure that a caregiver's or assistant caregiver's skills and knowledge are verified and documented before the caregiver or assistant caregiver provides physical health services..."

1. A review of E2's (hired as a caregiver) personnel record revealed the record did not include evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties.

2. A review of E3's (hired as a caregiver) personnel record revealed the record did not include evidence of E3's qualifications, including skills and knowledge applicable to E2's job duties.

3. A review of the facility's policies and procedures revealed a policy titled "Qualifications Caregivers (Certified) Skills/Training" dated September 2, 2020. The policy stated "All caregivers must have the skills necessary to provide assisted living services to assisted living residents."

4. In an interview, E1 reported to have skills and knowledge documentation for E2 and E3, however E1 forgot to fax the documentation to the facility. E1 acknowledged E2's and E3's personnel records did not include documentation of E2's and E3's qualifications, including skills and knowledge, applicable to E2's and E3's job duties.

Based on record review, documentation review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for two of three personnel records sampled. The deficient practice posed a risk if E2 and E3 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel records did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

R9-10-101.137. "Orientation" means the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution.

1. A review of E2's (hired as a caregiver) personnel record revealed the record did not include documentation of E2's completed orientation.

2. A review of E3's (hired as a caregiver) personnel record revealed the record did not include documentation of E3's completed orientation.

3. A review of the facility's policies and procedures revealed a policy titled "Employees and Volunteers Orientation and On-going Training Policy and Procedures" dated September 2, 2020. The policy stated "1. New staff and volunteers will be given an orientation forms/skills/knowledge verification form and it will be completed by the manager or manager's designee and the employee and volunteer before providing services...2. The manager or manager's designee will place the completed form in the new employee or volunteer's file."

4. In an interview, E1 reported to have completed orientation documentation for E2 and E3, however E1 forgot to fax the documentation to the facility. E1 acknowledged E2's and E3's personnel records did not include documentation of E2's and E3's completed orientation.

Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training, for one of two caregivers sampled. The deficient practice posed a risk if E2 was unable to meet a resident's needs, the Department was unable to determine substantial compliance as the personnel record did not include the documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Cardio Pulmonary [sic] Resuscitation and First Aid Policy and Procedures" dated September 2, 2020.

2. A review of E2's (hired as a caregiver in 2022) personnel record revealed the record did not include documentation E2's completed CPR or first aid training.

3. In an interview, E1 reported to have CPR and first aid training documentation for E2, and E1 reported E1 sent a fax of the documentation to the facility. E1 acknowledged E2's CPR and first aid training was not included in E2's personnel record.

Based on observation, record review and interview, the manager failed to ensure a personnel record for each employee included documentation in compliance with (C)(1)(c), for one manager sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the personnel record did not include the reuired documentation, and the documentation was not provided to the Department within two hours after a Department request.

Findings include:

R9-10-101.165 "Personnel member" means, except as defined in specific Articles in this Chapter and excluding a medical staff member, a student, or an intern, an individual providing physical health services or behavioral health services to a patient.

1. The Compliance Officer observed E1's manager's license posted to the wall with an issue date of July 7, 2022.

2. The Compliance Officer requested to review E1's (hired as a manager) personnel record. E1 faxed E1's personnel record to the facility and the Compliance Officer reviewed the following:
-An employment application with E1s name, date of birth, and contact telephone number;
-E1's starting date of employment;
-E1's education and experience applicable to E1's job duties; and
-Compliance with the requirements in A.R.S. \'a7 36-411(C)
However, the additional faxed pages were blank, the printer appeared to be out of ink, and documentation of
E1's qualifications, including skills and knowledge applicable to E1's job duties, E1's completed orientation and in-service education required by policies and procedures, evidence of freedom from infectious tuberculosis, cardiopulmonary resuscitation training (CPR) and first aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) was not available for review.

3. In an interview E1 reported to have the required documentation and acknowledged documentation to include E1's qualifications, including skills and knowledge applicable to E1's job duties, E1's completed orientation and in-service education required by policies and procedures, evidence of freedom from infectious tuberculosis, cardiopulmonary resuscitation training (CPR) and first aid training, and documentation of compliance with the requirements in A.R.S. \'a7 36-411(A) were not available for review.