KAYDIES ASSISTED LIVING HOME LLC

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. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented.

Findings include:

1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review.

2. A review E2's personnel record revealed initial training and continued competency training in fall prevention and fall recovery was not available for review.

3. In an interview, E2 acknowledged a training program for fall prevention and fall recovery training was not available for review and had not been developed. E2 reported E1 and E3 had been "trained" to a PowerPoint regarding fall prevention.

Based on documentation review, observation and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 36-425(I) A health care institution shall immediately notify the department in writing when there is a change of the chief administrative officer specified in section 36-422, subsection A, paragraph 1, subdivision (g).

1. A review of Department documentation revealed the certified assisted living facility manager (manager) was O1, ALM-010527, until November 30, 2022.

2. The Compliance Officer observed a manager's license on premises. The certificate number was ALM-010297 and was issued to E2.

3. In an interview, E2 reported O1 removed themselves as the manager and O2 became the manager briefly. E2 reported E2 became the manager in December 2022. E2 reported E2 had notified the Department of the change but was unable to provide documentation during the inspection the governing authority notified the Department when there was a change from O1 to O2 and when there was a change from O2 to E2.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 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.

Findings include:

1. The Compliance Officer requested the following at 12:30 PM:
-Employee disaster drills
-Resident and employee evacuation drills
-Disaster plan and annual review
-Three personnel records
-Two medical records
-Policies and procedures

2. The Compliance Officer conducted the exit interview with E2 at 3:15 PM and the following documentation had not been provided to the Department for review:
-Notification to the Department of the manager changes
-R1's documentation of freedom from infectious tuberculosis
-Disaster drills prior to December 2022

3. In an interview, E2 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's date of occupancy, for one of two residents sampled. The deficient practice posed a TB exposure risk to residents, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (admitted in 2023) medical record revealed evidence of freedom from infectious TB was not available for review.

2. In an interview, E2 reported to be unsure where the document providing evidence of freedom from infectious TB was for R1. E2 reported R1 had a TB test prior to being admitted into the facility but was unsure where the evidence was.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. A review of R2's (admitted in 2022) medical record revealed documentation dated within 90 calendar days before R2's date of admission, signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

2. In an interview, E2 acknowledged the manager failed to ensure before or at the time of R2's acceptance, R2 submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant

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.

Findings include:

1. The Compliance Officer observed the following medication on the kitchen counter:
-Dayquil liquid medication

2. The Compliance Officer observed the following in an unlocked medication closet:
-Medications for five residents

3. The Compliance Officer observed an unlocked caregiver room with the following:
-Two medisets containing medications belonging to E1 and another caregiver

4. The Compliance Officer observed three ambulatory residents on the premises.

5. In an interview, E1 and E2 acknowledged the medications were unlocked, accessible to residents, and were not stored in a separate locked room, closet, cabinet or self-contained unit.

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.

Findings include:

1. A review of facility documentation revealed an undated disaster plan. However, a disaster plan review was not available for review.

2. In an interview, E2 acknowledged a review of the disaster plan had not been completed at least once every 12 months.

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. The deficient practice posed a risk if employees were unable to implement a disaster plan, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed the facility's license was effective on February 19, 2021.

2. A review of the facility's staffing schedule, dated June 2023, revealed the facility maintained the following shifts:
-7 am - 7 pm (1st shift)
-7 pm - 7 am (2nd shift)

3. A review of facility documentation revealed the following disaster drills had been conducted:
-December 1, 2022 (1st shift - 9 am)
-December 1, 2022 (1st shift - 1 pm)
-March 15, 2023 (1st shift - 9 am)
-March 15, 2023 (2nd shift - 7 pm)

4. In an interview, E2 acknowledged the facility did not conduct a disaster drill on each shift at least once every three months. E2 reported the facility had a change of ownership and any drills conducted prior to December 2022 were not available for review.

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

Findings include:

1. A review of Department documentation revealed the facility's license was effective on February 19, 2021.

2. A review of the facility's documented evacuation drills revealed the following had been conducted:
-December 2, 2022
However, additional evacuation drills were not available for review

3. In an interview, E2 acknowledged the facility had not conducted an evacuation drill at least once every six months.