BROOKHAVEN ASSISTED LIVING

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three 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 E1's personnel record revealed E1 worked as the manager and had a hire date of September 1, 2023. The personnel record revealed a fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution.

3. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of July 27, 2023. The personnel record revealed a fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E3's fitness to work in a residential care institution.

4. Review of E4's personnel record revealed E4 worked as an assistant caregiver and had a hire date of September 24, 2023. The personnel record revealed a fingerprint clearance card. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E4's fitness to work in a residential care institution.

5. In an interview, E1 and E2 acknowledged documentation was not available that showed E1's, E3's, and E4's work references were obtained upon hire at the facility.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for two of four caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs.

Findings include:

1. Review of the facility's policy and procedure revealed a policy titled "Employee orientation and In-Service Training" that stated "1. All staff will receive a general orientation and job description training prior to beginning work in the facility...2. The Manager must ensure employees demonstrates competency in skills and techniques they are expected to perform prior to providing and direct care to the residents..."

2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of September 1, 2023. The personnel record revealed no documentation that showed E1 received orientation specific to the duties to be performed or demonstrated competency in skills and techniques E1 was expected to perform.

3. Review of E4's personnel record revealed E4 worked as and assistant caregiver and had a hire date of September 24, 2023. The personnel record revealed no documentation that showed E4 received orientation specific to the duties to be performed or demonstrated competency in skills and techniques E4 was expected to perform.

4. In an interview, E1 and E2 acknowledged documentation was not available that showed E1 and E4 had received orientation specific to the duties to be performed or demonstrated competency in skills and techniques E1 and E4 were expected to perform.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated June 7, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated August 24, 2023. This medication order stated "Primidone Tab 50mg Take 2 tablets by mouth once daily at bedtime".

3. Review of R1's medical record revealed an October 2023 medication administration record (MAR). This MAR stated "Mysoline 50mg tab take 2 tablets by mouth every night at bedtime (Dsp as: Primidone 50mg tab)" and indicated 2 tabs were administered at 8pm October 1st - 2nd. There was no documentation the medication was administered October 3rd - present.

4. During an observation of R1's medications, Primidone 50mg was observed.

5. In an interview, E1 reported two tabs of Primidone 50mg were administered per the medication order and E1 and E2 acknowledged R1's medical record did not include documentation the medication was administered October 3rd - present.