GOLDEN TIMES LLC

Based on record review and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. Review of E2, E3,and E4's personnel records revealed no documentation indicating E2, E3, and E4 completed fall prevention and fall recovery training.

2. During an interview, E2 acknowledged E2, E3, and E4 had not completed a training program for fall prevention and fall recovery.

Based on observation, documentation review, and interview, the governing authority failed to notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager and identify the name and qualifications of the new manager. The deficient practice posed a risk as the Department was unable to ensure the facility maintained a qualified manager.

Findings include:

1. A review of Department documentation revealed O1 was no longer the manager of AL12268 on January 14, 2023.

2. The Compliance Officer observed E1's license, issued by the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA), posted on the premises.

3. A review of E1's (hired in 2023) personnel record revealed E1 was hired as the licensed manager. However, documentation the Department was notified when there was a change in the manager was not available for review.

4. In an interview, E2 acknowledged the governing authority did not notify the Department according to A.R.S. \'a7 36-425(I) when there was a change in the manager.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of four employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411 states, "A...as a condition of employment in a residential care institution...employees and owners of residential care institutions...shall have valid fingerprint clearance cards... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution..."

2. Review of E3's personnel record revealed a fingerprint card. However, documentation was not available showing a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution.

3. During an interview, E2 acknowledged documentation was not available showing E3's work references were obtained upon hire at the facility.

Based on record review and interview, , the manager failed to ensure a personnel record included documentation of evidence of freedom from infectious tuberculosis (TB), for one of four personnel records reviewed which posed a potential health and safety risk of TB exposure, to residents and staff.

Findings include:

1. In record review, E4's personnel record (hired February 2023), included a chest x-ray dated February 10, 23, which documented a history of a positive PPD; however, included no further documentation of freedom from TB, as required.

2. In an interview, E2 acknowledged E4's personnel record did not include the required documentation of freedom from TB.

Based on record review and interview, the manager failed to ensure a residency agreement included whether the manager or a caregiver was awake during nighttime hours, for one of two residents reviewed accepted by the assisted living home on or after July 1, 2014. The deficient practice posed a health and safety risk if a resident was unable to awaken the caregivers during nighttime hours.

Findings include:

1. Review of R1's medical record revealed a residency agreement. However, this residency agreement did not include documentation of whether the manager or a caregiver was awake during nighttime hours. Based on R1's acceptance date, this documentation was required.

2. During an interview, E2 reported caregivers sleep at night but wake up for nighttime checks. E1 acknowledged R2's residency agreement did not include that information.

Based on documentation review, record review, and interview, the manager failed to ensure there was a documented residency agreement with the assisted living facility, for one of two current residents reviewed. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. Review of Department documentation revealed a change of ownership from AL2591to AL12268 on June 3, 2022.

2. Review of R2's medical record revealed a residency agreement between R2 and AL2591 prior to the change of ownership. However, an updated residency agreement between R2 and AL12268 was not available for review.

3. During an interview, E2 acknowledged R2's residency agreement was not updated after the change of ownership.

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

Findings include:

1. A review of R1's medical record revealed written service plan dated May 17, 2023. The service plan indicated R1 required assistance with bathing and oral care, however the service plan did not indicate the frequency of these services.

2. In an interview, E2 acknowledged R1's service plan did not include the frequency of assisted living services provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, when initially developed and when updated, signed and dated by the resident's representative, for one of two residents sampled. The deficient practice posed a risk if the resident's representative was unaware of the services to be provided to the resident at the facility.

Findings include:

1. A review of R1's medical record revealed a written service plan dated May 17, 2023, for directed care services. However, the service plan was not signed and dated by R1's representative.

2. In an interview, E1 acknowledged R1's service plan was not signed and dated by R1's representative.

Based on documentation review and interview, the manager failed to maintain at least 12 months of activity calendars after the last scheduled activity. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the required documentation was not available during the on-site inspection, and was not provided to the Department within two hours after a Department request.

Findings include:

1. The Compliance Officer requested activity calendars for the past 12 months. However, past activity calendars were not provided for review.

2. In an interview, E2 reported to be unaware of the activity calendars regulation. E2 acknowledged the activity calendars for the past 12 months had not been provided within two hours after a Department request.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs.

Findings include:

1. Review of R2's medical record revealed a current written service plan for directed care services dated February 8, 2023. This service plan stated "WC bound".

2. Review of R2's medical record revealed a written determination from R2's medical practitioner signed and dated May 25, 2022. However, documentation was not available stating R2's needs were met by the facility and R2's needs were within the facility's scope of services, at least once every six months.

3. During an interview, E2 acknowledged R2's medical practitioner did not provide a written determination upon the onset of the condition and every six months thereafter.

Based on documentation review and interview, the manager failed to ensure documentation of the disaster plan review included a critique of the disaster plan review.

Findings include:

1. A review of a document titled, "Disaster Plan Review Form" dated January 14, 2023 revealed the document included the date and time of the disaster plan review. However, there was no documentation of the name of each employee participating in the disaster plan review and the critique of the disaster plan review.

2. In an interview, E2 acknowledged the disaster plan review did not include the name of each employee participating in the disaster plan review and the critique of the disaster plan review.