THE VILLA AT BELLA VISTA

Based on documentation review, record review, and interview, the administrator failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of facility documentation revealed no documented policy for fall prevention and fall recovery.

2. A review of E1's, E2's, E3's, E4's, E5's, and E6's personnel records revealed no documentation to indicate E1, E2, E3, E4, E5, and E6 completed fall prevention and fall recovery training.

3. In an interview, E2 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery training.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training, including a demonstration of the individual's ability to perform CPR and documentation of current CPR training, for one of six personnel sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence E2 had the ability to perform CPR in an emergency.

Findings include:

1. A review of the facility's polices and procedures revealed a policy titled, "Staff Training." Under the heading, "Procedure," the policy stated, "New employee orientation will be completed within 10 days from start date and will include to [sic] following:...CPR current (adult)..."

2. A review of E2's personnel record revealed expired documentation of E2's CPR/First Aid training from the "National CPR Foundation" issued August 17, 2020 and valid for two years. In addition, the CPR training did not include a hands-on demonstration of techniques.

3. In an interview, E2 acknowledged the personnel record for E2 did not include current CPR training with hands-on demonstration as required.

Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented before providing physical health services for four of four caregivers and assistant caregivers reviewed. The deficient practice posed a risk if the employees were unable to meet a resident's needs.

Findings include:

1. A review of E3's personnel record revealed a hire date of May 4, 2022. E3's record revealed no documentation indicating E3's skills and knowledge were verified.

2. A review of E4's personnel record revealed a hire date of February 15, 2022. E4's record revealed no documentation indicating E4's skills and knowledge were verified.

3. A review of E5's personnel record revealed a hire date of October 28, 2020. E5's record revealed no documentation indicating E5's skills and knowledge were verified.

4. A review of E6's personnel record revealed a hire date of March 20, 2022. E6's record revealed no documentation indicating E6's skills and knowledge were verified.

5. In an interview, E2 acknowledged E3's, E4's, E5's, and E6's personnel records did not contain documentation showing E3's, E4's, E5's, and E6's skills and knowledge were verified. E2 reported E2 was actively working on updating personnel records and a method to verify and document skills and knowledge would be implemented as soon as possible.

Based on record review and interview, the manager failed to ensure before providing assisted living services to a resident, four of four sampled caregivers received orientation that was specific to the duties to be performed by the caregiver.

Findings include:

1. A review of E3's, E4's, E5's, and E6's personnel records revealed no documentation of completed orientation that was specific to the duties to be performed by E3, E4, E5, and E6.

2. In an interview, E2 acknowledged E3's, E4's, E5's, and E6's personnel records did not contain documentation of completed orientation that was specific to the duties in their job descriptions. E2 reported E2 was a new personnel member and could not confirm if E3, E4, E5, and E6 received orientation prior to providing services.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR) and first aid training , for one of six employees sampled.

Findings include:

1. A review of the facility's polices and procedures revealed a policy titled, "Staff Training." Under the heading, "Procedure," the policy stated, "New employee orientation will be completed within 10 days from start date and will include to [sic] following:...CPR current (adult), First aid training (current)..."

2. A review of E4's personnel record revealed no evidence to indicate E4 had completed any CPR or first aid training.

3. In an interview, E2 acknowledged the personnel record for E4 did not contain any evidence to indicate E4 had been trained in CPR or First Aid. E2 reported E4 was going to bring in E4's documentation the day of the survey at 4:00 PM.

Based on record review and interview, the manager failed to ensure a resident had a written service plan reviewed and updated at least once every three months for a resident receiving directed care services, for two of two residents sampled.

Findings include:

1. A review of R1's medical record revealed a service plan indicating R1 received directed care services. The service plan was dated April 6, 2022. However, subsequent reviewed or updated service plans were not available for review.

2. A review of R2's medical record revealed a service plan indicating R2 received directed care services. The service plan was dated March 10, 2022. However, subsequent reviewed or updated service plans were not available for review.

3. In an interview, E2 acknowledged R1's and R2's service plans were not reviewed and updated at least once every three months as required.

Based on documentation review, record review, and interview, the manager retained a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, without meeting the requirements in R9-814(B)(2), for one of two residents sampled who received directed care services.

Findings include:

1. R9-10-814(B)(2) states, "A manager of an assisted living facility authorized to provide personal care services may accept or retain a resident who is confined to a bed or chair because of an inability to ambulate even with assistance if: 2. The following requirements are met at the onset of the condition or when the resident is accepted by the assisted living facility: a. The resident or resident's representative requests that the resident be accepted by or remain in the assisted living facility; b. The resident's primary care provider or other medical practitioner: i. Examines the resident at the onset of the condition, or within 30 calendar days before acceptance, and at least once every six months throughout the duration of the resident's condition; ii. Reviews the assisted living facility's scope of services; and iii. Signs and dates a determination stating that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services and, for retention of a resident, are being met by the assisted living facility."

2. A review of R2's medical record revealed a service plan dated March 10, 2022. Under the heading "Ambulation,'' the service plan reported R2 was non-ambulatory.

3. A review of R2's medical record revealed documentation dated March 24, 2015. The documentation indicated R2 was authorized to reside in the assisted living facility. Further review of R2's medical record did not contain documentation of the facility's compliance with R9-10-814(B)(2)(b) every six months.

4. In an interview, E2 acknowledged R2 was retained as a resident without the facility being in compliance with R9-10-814(B)(2)(b). In an interview, E2 reported E2 was uncertain when R2 became non-ambulatory.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C), for four of six employees sampled. The deficient practice posed a risk to residents if the caregivers utilized were not vetted to ensure fitness to work with a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411(C) states, "1. Owners shall make documented, good faith efforts to: 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. Verify the current status of a person's fingerprint clearance card."

2. A review of E3's and E4's personnel records revealed E3 and E4 were hired as caregivers. However, documentation to indicate good faith efforts were made to contact previous employers to obtain information or recommendations relevant to E3's and E4's fitness to work in a residential care institution was not included in E3's and E4's personnel records.

3. A review of E2's, E3's, E4's and E6's personnel records revealed documentation to verify the current status of E2's, E3's, E4's, and E6's fingerprint clearance cards was not included in E2's, E3's, E4's and E6's personnel records.

4. In an interview, E2 acknowledged E2's, E3's, E4's and E6's personnel records did not include the documentation required in A.R.S. \'a7 36-411(C).