PRESTIGE HOME

INSP-0131008

Complete

Date: 5/12/2025

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2025-06-20

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on May 12, 2025:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

A.R.S. § 36-420.01.A. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for BLANK of BLANK personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, “Orientation, and In-Service Trainings for Employees.” The policy stated, “5. There shall be at least 12 hours of training each year for each caregiver providing directed care to residents. The training may include but is not limited to the following subjects… f. Resident emergency response procedures, such as Heimlich Maneuver, resident falls, and First Aid/CPR procedures…” 2. A review of E1’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on April 1, 2024. However, E1’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 3. A review of E2’s personnel record revealed documentation of completed fall prevention and fall recovery training conducted on April 1, 2024. However, E2’s personnel record did not include documentation of additional training on fall prevention and fall recovery. 4. In an interview, E2 acknowledged that the facility failed to administer a training program regarding fall prevention and fall recovery, for all staff, that included continued competency training. Technical assistance was provided regarding this regulation during the compliance inspection conducted on July 19, 2023.

Temporary Solution:

staff started training fall prevention and fall recovery with manger.

Permanent Solution:

Training was complete earned hours and fall prevention and fall recovery certification was given to each employee.

Person Responsible:

Piro Stawisuck Manager

Deficiency #2

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. 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 employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution, for three of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E1's date of hire, this documentation was required. 2. A review of E2's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E2's date of hire, this documentation was required. 3. A review of E3's personnel record did not include documentation of completed training on recognizing the signs and symptoms of TB. Given E3's date of hire, this documentation was required. 4. In an interview, E2 acknowledged E1's, E2's, and E3's personnel records did not include documentation of initial and annual training on recognizing the signs and symptoms of TB. Technical assistance was provided regarding this regulation during the compliance inspection conducted on July 19, 2023.

Temporary Solution:

facility had tuberculosis screening training forms so staff started study individual employee training with manager

Permanent Solution:

3 facility staff employees finished TB screening training to recognizing the signs and symptoms of tuberculosis. Before any caregiver starts they will be put through the TB training. Manager will facilitate the training to make sure the TB training is completed.

Person Responsible:

Pirjo Stawisuck

Deficiency #3

Rule/Regulation Violated:

R9-10-806.A.10. Personnel A. A manager shall ensure that: 10. Before providing assisted living services to a resident, a manager or caregiver provides current documentation of first aid training and cardiopulmonary resuscitation training certification specific to adults.

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training specific to adults, for one of three personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency. Findings include: 1. While on-site for the complaint inspection, the Compliance Officers observed E3 on-site and providing services to residents. 2. A review of E3's personnel record revealed a valid CPR certification dated December 5, 2023. However, E3’s personnel record did not include documentation of a first aid certification. 3. In an interview, E2 acknowledged E3's personnel record did not contain documentation of a current first aid training certification.

Temporary Solution:

Employee CPR cared was kept on file. Back up caregiver Tiffany filled in until CG got the first aid and CPR certificate.

Permanent Solution:

employee finished CPR and First Aide training and passed the test. all employees will be require to have cpr/first aid completed before providing services

Person Responsible:

pirjo stawisuck

Deficiency #4

Rule/Regulation Violated:

R9-10-810.B.3.b. Resident Rights B. A manager shall ensure that: 3. A resident or the resident's representative: b. Consents to photographs of the resident before the resident is photographed, except that a resident may be photographed when accepted as a resident by an assisted living facility for identification and administrative purposes;

Evidence/Findings:

Based on observation, record review, and interview, the manager failed to ensure the resident's or the resident's representative's consent to photographing the resident. Findings include: 1. During an environmental inspection, the Compliance Officers observed cameras being used in the facility. 2. R2's medical record did not contain a photographic consent form signed by the resident or the resident's representative. 3. In an interview, E2 acknowledged R2's medical record did not contain consent to photographs by the resident or the resident's representative.

Temporary Solution:

Caregiver called resident representative that photographic consent from admission papers must sign asap

Permanent Solution:

Resident representative came over and sign photographic consent form

Person Responsible:

Pirjo Stawisuck/ Manager

Deficiency #5

Rule/Regulation Violated:

R9-10-811.A.5. Medical Records A. A manager shall ensure that: 5. A resident's medical record is protected from loss, damage, or unauthorized use.

Evidence/Findings:

Based on observation and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. Findings Include: 1. During an environmental inspection of the facility, the Compliance Officers observed an open cabinet door. The door opened to reveal the resident's medical records and other documents. 2. In an interview, E2 acknowledged that resident medical records were not protected from loss, damage, or unauthorized use.

Temporary Solution:

Caregiver put then open door to secure door with baby lock.

Permanent Solution:

Caregiver bought a cabinet lock to replace the baby lock. cabinet opens with a key only now.

Person Responsible:

Piro Stawisuck

Deficiency #6

Rule/Regulation Violated:

R9-10-816.B.3.a-c. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure medication administration for a resident was in compliance with the medication orders. Findings Include: 1. A review of R1's medical record revealed a signed medication order dated March 3rd, 2025. Included on the list of medications was Colace 100mg 1 tab daily. 2. A review of R1's medication administration records revealed Colace 100mg was being administered twice daily. 3. In an interview, E2 acknowledged medication administration for R1 was not in compliance with the medication order.

Temporary Solution:

Manager deleted colace 100mg 2 tabs daily on the mars. Wrote in old order 100mg 1 tab daily and called dr to get new prescription order

Permanent Solution:

Doctor order for colace 100mg tab daily. and 1 capsule as needed. Medication order is in compliance with medication administration. Once new doctor orders are received, manager will go over dr order with all staff members to make sure everyone understands new doctor orders.

Person Responsible:

Pirjo Stawisuck

Deficiency #7

Rule/Regulation Violated:

R9-10-817.C.1. Food Services C. A manager shall ensure that food is obtained, prepared, served, and stored as follows: 1. Food is free from spoilage, filth, or other contamination and is safe for human consumption;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure that food stored by the facility was free from spoilage, filth, or other contamination and was safe for human consumption. Findings Include: 1. During an environmental inspection of the kitchen, the Compliance Officers opened a cabinet to reveal a bottle of syrup with the cap off, leaking, and covered in ants. 2. In an interview, E1 acknowledged that food stored by the facility was not free from spoilage, filth, or other contamination and was not safe for human consumption.

Temporary Solution:

Caregiver tossed away the bottle of syrup in the kitchen.

Permanent Solution:

Caregiver went through and cleaned the cabinet with soap and water. A new Pancake syrup bottle was brought in

Person Responsible:

Pirjo Stawisuck

Deficiency #8

Rule/Regulation Violated:

R9-10-819.A.1.b. Environmental Standards A. A manager shall ensure that: 1. The premises and equipment used at the assisted living facility are: b. Free from a condition or situation that may cause a resident or other individual to suffer physical injury;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury. Findings Include: 1. During an environmental inspection of the kitchen, the Compliance Officers opened a cabinet to reveal a bottle of syrup with the cap off, leaking, and covered in ants. 2. In an interview, the manager failed to ensure the premises and equipment used at the assisted living facility are free from a condition or situation that may cause a resident or other individual to suffer physical injury.

Temporary Solution:

Caregiver tossed bottle of syrup

Permanent Solution:

caregiver wet and cleaned cabinet with soap and water. Then Caregiver put label started when is expired date to the bottle of syrup

Person Responsible:

Pirjo stawsisuck

INSP-0082597

Complete

Date: 7/19/2023

Type: Compliance (Annual)

Worksheet: Assisted Living Home

SOD Sent: 2023-07-28

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on July 19, 2023:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that within 90 calendar days before or on the day the individual was accepted by an assisted living facility there was completed the required documented determination. The documentation should have included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; this was based on the date of acceptance, for one of one sampled resident record reviewed which posed a health and safety risk.

Findings include:

1. Review of R1's medical record revealed no documentation of a pre-admission determination on or prior to their dates of acceptance. Based on the resident's date of acceptance this documentation was required.

2. During an interview, E2 acknowledged there was no evidence the pre-admission determination was completed as required for this resident.

Deficiency #2

Rule/Regulation Violated:

A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that:
5. When initially developed and when updated, is signed and dated by:
a. The resident or resident's representative;
b. The manager;
c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and
d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.

Evidence/Findings:

Based on record review and interview, the manager failed to ensure two of three sampled residents' written service plans reviewed when initially developed and updated were signed and dated by the resident or resident's representative and the manager who reviewed the service plans, as required.

Finding included:

1. Review of R1's medical record and service plan revealed the resident required directed care and medication administration services. The current service plan dated May 4, 2023 was never signed by the resident or the representative who had reviewed this service plan.

2. Review of R3's medical record and service plan revealed the resident required personal care and medication administration services. The current service plan dated May 4, 2023 was never signed by the resident or the representative and the manager who had reviewed this service plan.

3. In an interview, E2 acknowledged that R1's and R3's service plans had not been signed and dated as required.

Deficiency #3

Rule/Regulation Violated:

C. A manager shall ensure that a resident's medical record contains:
17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);

Evidence/Findings:

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccination for pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccination available to a resident on site on a yearly basis; for one of one sampled resident record reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk.

Findings include:

1. Based on the date of acceptance, R3's medical record did not contain documentation to indicate R3 had received the pneumonia vaccine. There was no other documentation available in R3's medical record to indicate the vaccine had been offered, given, refused, or contraindicated within the past 12 months.

2. In an interview, E2 acknowledged there was no documentation available that this sampled resident had received the pneumonia vaccine or the vaccine had been made available to R3 during the past 12 months.

Deficiency #4

Rule/Regulation Violated:

C. A manager shall ensure that food is obtained, prepared, served, and stored as follows:
4. Potentially hazardous food is maintained as follows:
a. Foods requiring refrigeration are maintained at 41° F or below; and

Evidence/Findings:

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below which posed a health and safety risk.

Findings include:

1. During a facility tour, E2 and the compliance officer observed the facility's black kitchen refrigerator that contained food had a thermometer that registered 44.8\'b0 F at the warmest area of the refrigerator. The compliance officer's thermometer registered at 44.8\'b0 F. The refrigerator was not in use during the observation.

2. During an interview, E2 acknowledged the facility's refrigerator was not maintained at 41\'b0 F or below.

Deficiency #5

Rule/Regulation Violated:

A. A manager shall ensure that:
2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;

Evidence/Findings:

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months which posed a safety risk.

Findings include:

1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months. The most current documentation of the review of the disaster plan was dated April 27, 2022.

2. In an interview, E2 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months.

Deficiency #6

Rule/Regulation Violated:

A. A manager shall ensure that:
4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based on documentation reviewed and interview, the manager failed to ensure an employee disaster drill was conducted on each shift and documented which posed a safety risk.

Findings include:

1. During an interview, E2 provided documentation of the personnel schedule that revealed the facility had two shifts: First shift from 6:00 AM to 6:00 PM, the second shift from 6:00 PM to 6:00 AM.

2. There was no documentation of an employee disaster drill that had been conducted on the second shift during the past twelve months.

3. In an interview, E2 acknowledged the required employee disaster drills had not been conduct as required on the second shift.

Deficiency #7

Rule/Regulation Violated:

A. A manager shall ensure that:
11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were maintained in a locked area.

Findings include:

1. During a facility tour, E2 and the compliance officer observed the facility's kitchen cabinet under the kitchen sink was not locked and therefore could be easily opened. The cabinet contained unlocked chemicals: oven grill cleaner. disinfectant spray, ant and roach spray, furniture polish, and machine oil.

2. In an interview, E2 acknowledged the unlocked poisonous or toxic materials.

Facility Information

Inspection History

INSP-0131008

Summary:

Deficiencies Found: 8

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Temporary Solution:

Permanent Solution:

Person Responsible:

INSP-0082597

Summary:

Deficiencies Found: 7

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings: