CLEARWATER PINNACLE PEAK

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, which required employers to verify that fingerprint clearance cards were valid for four of ten sampled personnel records reviewed, which posted a safety risk.

Findings include:

1. Review of E3's personnel record, who was hired on November 3, 2022 in activities for memory care, included a copy of a fingerprint clearance card. There was no documentation the facility had verified on the DPS website that the fingerprint clearance card was valid at the time of hire nor any time since.

2. Review of E5's personnel record, who was hired on November 3, 2022 as a caregiver, included a copy of a fingerprint clearance card. There was no documentation that the facility had verified on the DPS website the fingerprint clearance card was valid at the time of hire nor any time since.

3. Review of E6's personnel record, who was hired on November 3, 2022 as caregiver, included a copy of a fingerprint clearance card. There was no documentation that the facility had verified on the DPS website the fingerprint clearance card was valid at the time of hire nor any time since.

4. Review of E9's personnel record, who was hired on November 3, 2022 for maintenance and who services resident's units, included a copy of a fingerprint clearance card. There was no documentation that the facility had verified on the DPS website the fingerprint clearance card was valid at the time of hire nor any time since.

5. In an interview, E1 and E10 acknowledged these four sampled employees fingerprint clearance cards had not been verified with DPS as valid fingerprint cards.

6. After exiting the compliance inspection, the compliance officer verified on the DPS website that all four sampled employees had valid fingerprint clearance cards.

Based on observation and interview, the manager failed to ensure the location at which a copy of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed was conspicuously posted.

Findings include:

1. During a facility tour, E1 and the compliance officer observed the posted notification of the location of the most recent Department inspection report and any plan of correction resulting from the Department inspection may be viewed could not be located. The definition of "conspicuously posted" per the definition in A.A.C. R9-10-101(54) as a visible and available area that the public enters the premises of the health care institution.

2. In an interview, E1 acknowledged the required inspection notice was not conspicuously posted as required.

Based on record review and interview, the manager failed to ensure that before providing assisted living services to a resident, a caregiver provided current documentation of cardiopulmonary resuscitation (CPR) training certification specific to adults which posed a health and safety risk for two of four personnel records reviewed who were required to complete first aid and CPR training.

Findings include:

1. Review of E2's personnel record reveal that E2 was hired November 3, 2022. E2's record contained a copy of a CPR card that had expired on September 20, 2023. E10 acknowledged the expired CPR card.

2. Review of E5's personnel record revealed that E5 was hired on October 3, 2022 to work as a caregiver. E5's personnel record contained a document from NaionalCPR Foundation that was issued on October 19, 2022 and valid for two years. This training was an online-only CPR training and did not include a return demonstration.

3. In an interview, E1 and E10 acknowledged this online CPR training program and that E5 was working as a caregiver and E2 had an expired CPR training certificate.

Based on record review and interview, the manager failed to ensure a written service plan included how a medication would be stored and controlled, for one of two sampled residents who were storing medications in the resident's unit, which posed a health and safety risk.

Findings include:

1. In interview, E2 reported that R4 was allowed to manage R4's own medications. R4 was in the unit and acknowledge that R4 was self-administrating R4's own medications.

2. R4's current service plan, dated September 26, 2023, failed to state how R4's medications would be stored and controlled in R4's unit.

3. In an interview, E1 and E2 acknowledged the sampled resident was allowed to self-administer R4's own medications, however, R4's service plan did not include how these medications will be stored and controlled.

Based on record review and interview, the manager failed to ensure that five of five sampled residents who were unable to ambulate even with assistance, the residents' primary care provider (PCP) or other medical practitioner signed a determination stating that the residents' needs were being met. This determination was to be completed at the time of acceptance or onset and at least once every six months throughout the duration of the residents' condition to determine if the resident's needs could be met based upon a current resident examination and the assisted living facility's scope of services which posed a health and safety risk. The facility is licensed to provided directed care services.

Findings include:

1. During an interview, E2 reported that R1, R2, R8, R9, and R10 were unable to ambulate even with assistance for the past 12 months or since onset.

2. Review of R1's medical record revealed a documented determination completed on November 8, 2023. However, there was no updated determination at least every six months throughout the duration of the resident's condition during this past 12 months. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R1 required personal care services.

3. Review of R2's medical record revealed a documented determination completed on March 27, 2023. However, there was no updated determination at least every six months throughout the duration of the resident's condition since the onset of this condition. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R2 required personal care services.

4. Review of R8's medical record revealed a documented determination completed on November 1, 2023 and January 19, 2023. However, there was no updated determination at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R8 required directed care services.

5. Review of R9's medical record revealed a documented determination completed on November 1, 2023 and January 9, 2023. However, there was no updated determination at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R9 required directed care services.

6. Review of R10's medical record revealed a documented determination completed on November 1, 2023 and January 25, 2023. However, there was no updated determination at least every six months throughout the duration of the resident's condition. This determination should have been based on a resident's current examination and the facility's scope of services that the resident's needs could be met. R10 required directed care services.

7. In an interview, E2 acknowledged the determinations were not completed as required. E2 reported, "I forgot to do them".

Based on observation and interview, the manager failed to ensure the premises and equipment were free from a condition or situation that may cause a resident or other individual to suffer physical injury which posed a health and safety risk.

Findings include:

1. During a facility tour of randomly selected residents' units, E1 and the compliance officer observed in R2's unit's bathroom the corners of the walls were broken by the shower and another area near the sink. The walls were broken down to the wall's raw frame which allowed moisture to get into these areas and the resident or other individual may suffer physical injury if they rubbed up against these broken areas.

2. In the facility's central kitchen there was a large tank of CO 2 that was not secured. The tank could cause physical injury if tipped over.

3. In an interview, E1 acknowledged the broken walls in the bathroom and the unsecured CO 2 tank that could become a point of hazard and physical injury.



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Based on observation and interview, the manager failed to ensure that garbage and refuse are stored in covered containers.

Findings include:

1. During a tour of the facility central kitchen, E1 and the compliance officer observed large gray trash barrels, not in use at the time of the inspection, containing trash and food products.

2. In an interview with E1 and the kitchen staff, they informed the compliance officer there were no covers for these trash barrels.

3. In an interview, E1 acknowledged the uncovered trash in the facility's central kitchen.

Based on observation and interview, the manager failed to ensure the hot water temperatures were maintained between 95\'ba F and 120\'ba F in areas of an assisted living facility used by residents.

Findings include:

1. During a tour of randomly selected areas of the facility, E1 and the compliance officer observed in R10's bathroom the hot water temperature registered on the compliance officer's thermometer at 126.3\'ba F.

2. In an interview, E1 acknowledge the facility's hot water was over 120\'ba F in areas of the facility that are used by residents.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in closed containers away from food storage, kitchen, and dining areas, which posed a health risk.

Findings include:

1. During a tour of the facility's memory care units' food prep kitchens, E1 and the compliance officer observed in the prep kitchens on both first and second floor, there were stored uncovered bins full of soiled linen.

2. In an interview, E1 acknowledged the uncovered soiled linen being stored by the facility.

Based on observation and interview, the manager failed to ensure a oxygen container was secured, which posed a safety risk.

Findings include:

1. During a tour of randomly selected areas of the facility, E1 and the compliance officer observed in R6's unit there was stored one unsecured oxygen container.

2. In an interview, E1 acknowledged the unsecured oxygen container.