MADERA ASSISTED LIVING HOME

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training, for one of three personnel sampled. The deficient practice posed a health and safety risk for residents.

Findings include:

1. A review of E3's personnel record did not include documentation of Fall Prevention and Fall Recovery training. Based on E3's date of hire, this documentation was required.

2. In an interview, E1 acknowledged documentation of E3's Fall Prevention and Fall Recovery training was not available for review.

Based on observation, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services, for two of three personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. While on-site for the complaint inspection, the Compliance Officers observed E1 and E2 on-site and providing services at the facility.

2. A review of E1's personnel record did not include documentation of the verification of E1's skills and knowledge.

3. A review of E2's personnel record did not include documentation of the verification of E2's skills and knowledge.

4. In an interview, E1 acknowledged E1's and E2's personnel records did not include documentation of the verification of E1's and E2's skills and knowledge before E1 and E2 provided health services.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents.

Findings include:

1. While on-site for the compliance inspection, the Compliance Officers observed E1 working at the facility.

2. A review of the facility's employee work schedule, for December 27, 2024, revealed E1 was not scheduled to work at the facility. No further documentation of the caregivers scheduled to work, and hours worked by each was available for Compliance Officer review.

3. In an interview, E1 reported the scheduled personnel member was out of town. E1 acknowledged the employee work schedule did not include documentation of the caregivers who worked each day, and the hours worked by each.

Based on documentation review, record review, and interview, the manager failed to ensure that a personnel record for each employee or volunteer included documentation of cardiopulmonary resuscitation (CPR) training and first aid (FA) training, if required per the facility's policies and procedures, for one of three personnel sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an emergency.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "Policy on ARS 36-420: Health care institutions; cardiopulmonary resuscitation; first aid; immunity; falls (Ref AB1373)." The policy stated, "1. Cardiopulmonary Resuscitation (CPR) proof of training is mandatory for all staff prior to providing care and services. "

2. A review of E3's personnel file did not include documentation of CPR/FA training. Given E3's date of hire, this documentation was required.

3. In an interview, E1 acknowledged E3's personnel file did not include documentation of CPR/FA training as required in the facility's policies and procedures.

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

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

2. While on-site for the complaint inspection, the Compliance Officers observed the front door and back door were equipped with an alarm to alert employees of egress; however the alarms were not turned on at the time of inspection.

3. In an interview, E1 reported the facility will ensure alarms are turned on at all times. E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on observation and interview, the manager failed to ensure that foods requiring refrigeration was maintained at 41\'b0 F or below. The deficient practice posed a risk for potential food borne illnesses.

Findings include:

1. While on-site for the complaint inspection, the Compliance Officers observed the following foods stored in a kitchen pantry:
- Kikkoman Soy Sauce;
- Kikkoman Sukiyaki Sauce; and
- Kikkoman Teriyaki Sauce.
However, the labels of the aforementioned products stated, "refrigerate after opening."

2. In an interview, E1 acknowledged the potentially hazardous foods were not maintained at 41\'b0 F or below.

Based on observation and interview, the manager failed to ensure that a refrigerator used by the assisted living facility to store food or medication contained a thermometer, accurate to plus or minus 3\'b0 F, placed at the warmest part of the refrigerator. The deficient practice posed a risk for potential food borne illnesses.

Findings include:

1. While on-site for the complaint inspection, the Compliance Officers observed the thermometer in the kitchen refrigerator, used for food storage, with a temperature reading of 50\'b0 F.

2. In an interview, E1 acknowledged that the refrigerator used by the assisted living facility to store food or medication did not contain a thermometer, accurate to plus or minus 3\'b0 F