SUNRISE CARE HOMES SUNNYVALE

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 a risk to the physical health and safety of residents with access to unsecured medication.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed the unlocked medication cabinet in the front living room common area. The medication contained medication for nine of the residents at the facility.

2. During the environmental inspection of the facility, the Compliance Officer observed the unlocked medication lockbox in the refrigerator containing medication, the lockbox was unlocked and had the key in the lockbox, also the key to the lockbox was tied to the shelf in the refrigerator.

3. In an interview, E2 acknowledged the medication in the medication cabinet and in the refrigerator was unlocked and the aforementioned medications were accessible to residents at the facility.

Based on documentation review, record review and interview, the health care institution failed to administer a training program regarding initial training and continued competency training for fall prevention and fall recovery, for three of three 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 that the health care institution had developed a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01.

2. A review of E1, E2, and E3's personnel records revealed documentation for initial training and continued competency training titled "Fall Prevention," however the initial training and continued competency training did not include fall recovery.

3. In an interview, E4 acknowledged personnel records for E1, E2, and E3 only indicated initial training and continued competency training for fall prevention and the facility was not in compliance with A.R.S. \'a7 36-420.01.

Based on observation, record review, documentation review, and interview, the governing authority failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411, for one of three personnel records sampled. The deficient practice posed a risk if E1 was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411 states, "A... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..."

2. During the environmental tour, the Compliance Officer observed E1's manager licenses conspicuously posted.

3. A review of E1's personnel record revealed E1 was hired as the facility manager September 01, 2023.

4. A review of E1's personnel record revealed a fingerprint clearance card with an expiration date of February 22, 2024.

5. A review of the website from the Arizona Department of Public Safety revealed E1's fingerprint card expired on February 22, 2024.

6. In an interview, E2 and E4 acknowledged E1 did not have a valid fingerprint clearance card and the facility was not in compliance with the requirements in A.R.S. \'a7 36-411.

Based on documentation review, observation, and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area from which a resident could exit to a location at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if facility staff were unaware of the egress of a resident from the facility.

Findings include:

1. A review of Department records revealed the facility was licensed to provide directed care services.

2. During the environmental tour, the Compliance Officer observed two doors located near the TV room and a hallway leading to the side yard. However, the doors were not secured and there were no devices to alert employees.

3. During the environmental tour, the Compliance Officer observed french doors between a resident room and a hallway leading to the back yard. However, the doors were not secured and the door chimes were not activated.

4. During the environmental tour, the Compliance Officer observed french doors in bedroom 8 leading to the back yard. However, the doors were not secured and there were no devices to alert employees.

5. A review of facility documentation revealed a policy and procedures titled "Safety of Wandering Residents," the policy stated "5. If alarms are being used on doors and/ or windows, the caregiver will check them daily for operation and security."

6. In an interview, E2 and E3 acknowledged a means of exiting the facility to an outside area that allowed a resident to be at least 30 feet away from the facility did not control or alert employees of the egress of a resident from the facility.