R & D MARATHON ASSISTED LIVING HOME II

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 (C) (1), for one of four personnel records sampled. The deficient practice posed a risk if the personnel were a danger to a vulnerable population and the Department was unable to determine substantial compliance as the required documentation was not provided during the inspection.

Findings include:

1. A.R.S. \'a7 36-411 states, "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, nursing care institution or home health agency."

2. A review of E1's personnel record revealed E1 was hired as the manager on December 01, 2021. However, there was no documentation of good faith efforts to contact E1's previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.

3. In an interview, E2 and E4 acknowledged documentation was not available that showed E1's work references were obtained upon hire at the facility.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.

Findings include:

1. A review of facility documentation revealed the facility policy and procedure manual was last reviewed in November 2019. The facility policy stated "The Policies and Procedures Manual is available ... It is reviewed at least once every three years and updated as needed." However, documentation to indicate the policies and procedures were reviewed at least once every three years was not available for review.

2. In an interview, E2, E3 and E4 acknowledged the policies and procedures were not reviewed at least once every three years.

Based on observation and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents.

Findings include:

1. When the Compliance Officer arrived, E3 was the only personnel member working at the facility.

2. During the environmental tour, the Compliance Officer observed there was no personnel schedule posted for the month of June.

3. In an interview, E3 reported the personnel schedule fell off the notice board, however, was not able to provide the documentation to the department.

4. In the exit interview, E2, E3 and E4 acknowledged documentation was not maintained of the caregivers working each day, including the hours worked for the month of June.

Based on documentation review, record review and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of the individual's completed in-service education required by policies and procedures, for two of four personnel members sampled.

Findings include:

1. R9-10-101.103. states "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer.

2. A review of facility documentation revealed a policy and procedure titled "In-Service Education/ Training For Caregivers," the policy stated "5. There shall be at least 12 hours of training each year for each caregiver providing directed care to residents."

3. A review of E1's personnel record revealed E1 was hired as the manager in December 2021. The personnel record for E1 indicated the facility conducted an in-service education for fall prevention and recovery in 2023 and 2024, however, this documentation did not indicate the total hours of in-service education. E1's personnel record revealed in-service education in total of 12 hours for 2022 and 2023 was not available for review.

4. A review of E2's personnel record revealed E2 was hired as caregiver in February 2022. The personnel record for E2 indicated the facility conducted an in-service education for fall prevention and recovery in 2023 and 2024, however, this documentation did not indicate the total hours of in-service education. E2's personnel record revealed in-service education in total of 12 hours for 2023 was not available for review.

5. In an interview, E2, E3 and E4 acknowledged documentation was not available showing E1 and E2 completed in-service education required by policies and procedures.

Based on observation, documentation review and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist.

Findings include:

1. During the environmental tour, the Compliance Officer observed the facility provided medication administration services.

2. A review of facility documentation revealed a policy titled, "Medication Services," the policy stated "2. Medication policies and procedures are reviewed and approved by a medical practitioner, registered nurse, or pharmacist." However the medication services policy and procedure were not reviewed as required by a medical practitioner, registered nurse, or pharmacist.

3. In an interview, E2, E3 and E4 acknowledged documentation was not available that showed the medication services policy and procedure was reviewed by a medical practitioner, registered nurse, or pharmacist.

Based on observation and interview, the manager failed to ensure medications stored by the facility were 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 not prescribed the accessible medication.

Findings include:

1. During an environmental tour, the Compliance Officer observed two ambulatory residents on the premises.

2. The Compliance Officer observed the following medication unlocked in the kitchen refrigerator:
- "LANTUS INJ SOLOS 100U/MLX3"

3. In an interview, E2, E3 and E4 acknowledged the medication was stored unlocked.

Based on observation and interview, the manager failed to ensure food was protected from potential contamination. The deficient practice posed a potential health risk to the residents.

Findings include:

1. During the environmental tour, the Compliance Officer observed the following item in the kitchen refrigerator:
- sliced apples stored in the refrigerator door, left in the open;
- sliced limes stored in the refrigerator door, left in the open; and
- open can of sweetened condensed milk with no lid or covering

2. In an interview, E2, E3 and E4 acknowledged the uncovered food was not protected from potential contamination.

Based on observation and interview the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses.

Findings include:

1. During a facility tour with E1, the Compliance Officer observed a refrigerator located in the kitchen of the facility had a thermometer which registered at 50\'b0F. The Compliance Officer placed a Department issued thermometer in the refrigerator for 30 minutes. The refrigerator was not accessed during this time and the thermometer read 55\'b0 F.

2. The Compliance Officer observed the refrigerator contained foods requiring refrigeration, including juice, salad dressing, milk, sour cream, eggs, leftovers and resident medication.

3. In an interview, E1 acknowledged potentially hazardous foods requiring refrigeration were not maintained at 41\'b0F or below.

Based on observation and interview, the manager failed to ensure the bathroom accessible from a common area contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control.

Findings include:

1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available for bathrooms in the common area used by residents, personnel and visitors.

2. In an interview, E2, E3 and E4 reported the facility was out of paper towels and acknowledged the bathrooms accessible from common areas did not contained paper towels in a dispenser or a mechanical air hand dryer.

Based on observation and interview, the manager failed to ensure a resident bathroom used by more than one resident contained paper towels in a dispenser or a mechanical air hand dryer. The deficient practice posed a potential risk to infection control.

Findings include:

1. During the environmental tour, the Compliance Officer observed there were no paper towels in a dispenser or a mechanical air hand dryer available in the bathrooms for resident bedroom 1 and 2, as well as the shared bathroom for resident bedroom 3.

2. In an interview, E2, E3 and E4 reported the facility was out of paper towels and acknowledged the bathrooms used by more than one resident did not contained paper towels in a dispenser or a mechanical air hand dryer.