R & D MARATHON ASSISTED LIVING HOME III LLC

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently.

Findings include:

1. A review of E1's personnel record revealed E1 did not have documentation of fall prevention and fall recovery training.

2. In an interview, E6 reviewed and acknowledged E1's record did not have documentation of fall prevention and fall recovery training.

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 five personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

Finding include:

1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work."

2. A review of E2's personnel record revealed a fingerprint clearance card that expired on May 29, 2024. E2's record reflected E2's fingerprint was verified on July 1, 2024.

3. The compliance officer (CO) observed E2 to be the only licensed caregiver on-site upon the CO's arrival.

4. A review of the facility's schedule dated October 2024 revealed E2 was scheduled as a caregiver.

5. In an interview, E6 reviewed and acknowledged E2's record did not contain a valid fingerprint clearance card. E6 reported E2 would apply for a new one "Tomorrow".

Based on interview and documentation review, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center is authorized to provide.

Findings include:

1. A review of Department documentation revealed the facility was authorized to provide directed care services.

2. The Compliance Officer requested to review the facility's policy and procedure to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. However, E6 was unable to locate the aforementioned policy and procedure for review.

3. In an interview, E6 reviewed the facility's policy and procedures acknowledged this policy was not documented that covers the methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving personal care services.

Findings include:

1. During a facility tour with E1, the compliance officer observed resident bedrooms labeled "1" which contained R3, and bedroom labeled "7" which contained R2 , which did not have a bell, intercom, or other means to alert employees to needs or emergencies. The surveyor observed no other means to alert a caregiver to the residents needs.

2. A review of R2's and R3's medical records revealed R2 and R3 were personal level of care.

3. In an interview with E6, E1 acknowledged that bedrooms labeled "1", and "7" , which contained residents, did not have a bell, intercom, or other means to alert employees to needs or emergencies.

4. In an interview, E6 reported bells were the means used to alert employees of a resident's needs. E6 acknowledged during the tour, the above resident rooms did not have bells.

Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services.

Findings include:

1. During a facility tour with E1, the compliance officer observed resident bedrooms labeled "4" which contained R4 did not have a bell, intercom, or other means to alert employees to needs or emergencies. The surveyor observed no other means to alert a caregiver to the resident's needs.

2. A review of R4's medical record revealed R4 was directed level of care.

3. In an interview with E6, E1 acknowledged that bedrooms labeled "4" which contained R4 did not have a bell, intercom, or other means to alert employees to needs or emergencies.