AHWATUKEE ADULT CARE III

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and, if an individual was requesting or expected to receive supervisory care services, personal care, services, or directed care services, was dated and signed by a Physician, Registered nurse practitioner, Registered nurse, or Physician assistant, for one of three residents sampled.

Findings include:

1. A review of R2's medical record revealed a document titled, "Determination Letter," which did not state if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services. The document was signed dated by a Physician. No other documentation dated within 90 calendar days before R2 was accepted by an assisted living facility and signed by a Physician, Registered nurse practitioner, Registered nurse, or Physician assistant which stated if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services was available for review.

2. In an interview, E3 acknowledged R2's "Determination Letter" form did not state if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services.

Based on record review and interview, the manager failed to ensure that before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by an assisted living facility, and, if an individual was requesting or expected to receive supervisory care services, personal care, services, or directed care services, was dated and signed by a Physician, Registered nurse practitioner, Registered nurse, or Physician assistant, for one of three residents sampled.

Findings include:

1. A review of R2's medical record revealed a document titled, "Determination Letter," which did not state if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services. The document was signed dated by a Physician. No other documentation dated within 90 calendar days before R2 was accepted by an assisted living facility and signed by a Physician, Registered nurse practitioner, Registered nurse, or Physician assistant which stated if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services was available for review.

2. In an interview, E3 acknowledged R2's "Determination Letter" form did not state if R2 was requesting or expected to receive supervisory care services, personal care, services, or directed care services.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a health and safety risk to residents with access to the medications.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked medication cabinet in the common area. The unlocked medication cabinet contained medication for six residents.

2. In an interview, E2 And E3 acknowledged the medications were not stored in a locked area and were accessible to residents.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked area. The deficient practice posed a health and safety risk to residents with access to the medications.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked medication cabinet in the common area. The unlocked medication cabinet contained medication for six residents.

2. In an interview, E2 And E3 acknowledged the medications were not stored in a locked area and were accessible to residents.

Based on documentation review, record review and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the survey, and was not provided within two hours after a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "FALL PREVENTION AND FALL RECOVERY TRAINING" (undated). The policy stated "Falls put you at risk of serious injury. Prevent falls with these simple fall-prevention measures..." However, the policy did not include the initial training and continued competency training requirement.

2. A review of E3's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

3. In a joint interview, E1 and E2 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the following documentation was not provided for review: documentation of first aid training for E3, and documentation of fall prevention and fall recovery for E3.

Findings include:

1. A review of E3's personnel record revealed documentation of current cardiopulmonary training and Basic Life Support training. However, documentation of first aid training was not available for review.

2. A review of E3's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review.

3. In a joint interview, E1 and E2 acknowledged the aforementioned documentation was not provided for review within two hours after a Department request.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of first aid training, for one of five personnel records sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs during an accident or injury the Department was unable to determine substantial compliance as the documentation was not in the medical record at the time of the inspection, and the documentation was not provided within two hours of a Department request.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "CPR AND FIRST AID" (undated). The policy stated "It is the policy of this facility to ensure that all facility staff is trained in CPR and First Aid and that their certification is maintained and in current as long as they are employed by this facility. In order to keep First Aid and CPR training and skills up to date, it is required that each employee and volunteer to provide the following: 1. Documentation that verifies the employee or volunteer has received CPR and First Aid training...Each employee or volunteer will present proof of training of CPR and First Aid..."

2. A review of E3's (hired in June 2022) personnel record revealed documentation of current cardiopulmonary training (CPR) and Basic Life Support (BLS) training. However, documentation of first aid training was not available for review.

3. In a joint interview, E1 and E2 acknowledged E3's documentation of first aid training was not available for review.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials were stored in a locked area inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident.

Findings include:

1. The Compliance Officer observed ambulatory residents on the premises.

2. The Compliance Officer observed in a shared bathroom an unlocked cabinet, under the bathroom sink, the following poisonous or toxic material:
-"Lysol Fresh Cleaning Gel."

3. In a joint interview, E1 and E2 acknowledged the poisonous or toxic material stored by the facility was not stored in a locked area and were accessible to residents.