BROOKDALE TEMPE

Based on documentation review, record review, and interview, the manager failed to ensure an caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services on behalf of the facility, for four of four sampled caregiver and assistant caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents.

Findings include:

1. A review of facility documentation staffing schedules revealed staffing schedules for the previous 12 months. The schedules revealed E2, E3, E4, and E5 were each scheduled to work at the facility as caregivers or assistant caregivers on multiple shifts throughout August 2023-May 2024.

2. A review of E2's, E3's, E4's, and E5's personnel records revealed no documented verification of E2's, E3's, E4's, or E5's skills and knowledge.

3. In an interview, E1 acknowledged E2's, E3's, E4's and E5's personnel records did not contain documented verification of skills and knowledge.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411(C), for four of seven personnel sampled. The deficient practice posed a risk if previous employers contained relevant information regarding E3's, E5's, E6's and E7's fitness to work.

Findings include:

1. A review of E3's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

2. A review of E5's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

3. A review of E6's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

4. A review of E7's personnel record revealed a valid fingerprint clearance card. However, documentation of compliance with A.R.S. \'a7 36-411(C)(1) was not available for review.

5. In an interview, E1 and E2 acknowledged E3's, E5's, E6's, and E7's personnel records did not contain documentation of compliance with A.R.S. \'a7 36-411(C)(1).

Based on record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery, for two of seven personnel sampled. The deficient practice posed a risk to the health and safety of residents.

Findings include:

1. A review of E5's personnel record revealed completed training for fall prevention and fall recovery was not available for review.

2. A review of E7's personnel record revealed completed training for fall prevention and fall recovery was not available for review.

3. In an interview, E1 and E2 acknowledged E5 and E7 were missing completed training in fall prevention and fall recovery.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers, for one of five personnel sampled. The deficient practice posed a risk if the caregiver was not trained to provide caregiver services to residents in the assisted living facility.

Findings include:

1. A review of E5's personnel record revealed a document titled, "Certified Caregiver." The document stated, "This certificate verifies that [E5] Has completed an Arizona Department of Health Services Approved Caregiver course for Assisted Living Facilities. On May 3, 2002 [E5] completed 62 hours Of instruction: Supervisory care - 20 hours; Personal Care - 30 hours; Directed Care - 12 hours..." The document included the name and address of the location and was signed by O1. However, the document did not include an Assisted Living Training Program number.

2. A review of Department documentation revealed O1 or the facility location was never licensed as an approved caregiver training program.

3. In an interview, E1 and E2 acknowledged E5 did not provide documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrator and Assisted Living Facility Managers.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation required by the policies and procedures for five of seven personnel sampled. The deficient practice posed a risk if personnel were not orientated to the specific job expectation and requirements.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "Orientation and Training," dated August 2022, which stated, "...1. When an associate is hired, the appropriate Competency Assessment/Orientation Checklist should be completed and maintained in the Associate File...3. The associate and supervisor should sign and date the Competency Assessment/Orientation Checklist upon completion..."

2. A review of E3's personnel record revealed a document titled, "Orientation/Checklist for New Associates." The document had E3's name on it and the date it was initiated, however the rest of the document was only partially completed and was missing the signature and date signed of E3 and a supervisor.

3. A review of E4's personnel record revealed documentation of orientation was not available for review.

4. A review of E5's personnel record revealed documentation of orientation was not available for review.

5. A review of E6's personnel record revealed documentation of orientation was not available for review.

6. A review of E7's personnel record revealed documentation of orientation was not available for review.

7. In an interview, E1 and E2 acknowledged documented evidence of completed orientation was missing from E3's, E4's, E5's, E6's, and E7's personnel records.

Based on record review and interview, the manager failed to ensure a resident had a written service plan, that when initially developed and when updated, was signed and dated by the resident or resident's representative and the manager, for three of five residents sampled. The deficient practice posed a risk if service plans were not authenticated to show the resident and manager were involved in the development of the service plans.

Findings include:

1. A review of R1's medical record revealed a service plan dated March 10, 2023. The document was signed by E1, however, was missing a signature from the resident or the resident's representative.

2. A review of R4's medical record revealed a service plan dated March 15, 2023. The was missing a signature from the manager and the resident or the resident's representative.

3. A review of R5's medical record revealed a service plan dated January 17, 2023. The was missing a signature from the manager and the resident or the resident's representative.

4. In an interview, E1 and E2 reported R1's representative refused to signed R1's service plan, and the facility was waiting to meet with R4's and R5's representatives to obtain their signatures on R4's and R5's service plans.

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for three of five residents sampled. The deficient practice posed a risk of potential TB exposure if screening tests were not completed as required.

Findings include:

1. A review of R1's medical record revealed R1 was admitted in 2022. However, R1's medical record revealed documentation of evidence of freedom from infectious TB was not available for review.

2. A review of R2's medical record revealed R2 was admitted in 2022. However, R2's medical record revealed documentation of evidence of freedom from infectious TB was not available for review.

3. A review of R5's medical record revealed R5 was admitted in 2022. However, R5's medical record revealed documentation of evidence of freedom from infectious TB was not available for review.

3. In an interview, E1 and E2 acknowledged R1's, R2's, and R3's medical records did not contain documentation of freedom from infectious TB.

This is a repeat deficiency from an inspection conducted on September 9, 2022.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served.

Findings include:

1. During a facility tour, the surveyor observed a food menu conspicuously posted for residents on the wall of the dining room for the week of March 28, 2023, through April 1, 2023.

2. During a facility tour, the surveyor observed a current menu posted inside the facility's kitchen accessible only to staff.

3. In an interview, the kitchen manager reported to have not yet changed the menu in the dining room to the current menu.

3. In an interview, E1 and E2 acknowledged the facility's food menu, conspicuously posted for residents, was out of date.