Lakeview Assisted Living.

“Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Fall and Fall Prevention.” The policy stated, “All new caregivers will have training on fall prevention one month after hire date. All caregivers will have a fall prevention training every year or every six months if there are at least 2 incidents of resident falls for the quarter.”  2. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. A review of E1’s personnel record revealed no fall prevention and fall recovery training.  3. A review of E2's personnel record revealed E2’s hire date of November 30, 2013. A review of E2’s personnel records revealed the following:  Fall prevention training completed on July 12, 2024. No fall recovery training. No training per facility policy.  4. A review of E3's personnel record revealed E3’s hire date of December 6, 2016. A review of E2’s personnel record revealed the following:  Fall prevention training completed in 2024. No fall recovery training for 2024 and 2025. No training per facility policy.  5. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 6. This is a repeat deficiency from the compliance inspection conducted on July 13, 2023.”

“Based on record review, documentation review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities, including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution and annually assessing the health care institution's risk of exposure to infectious tuberculosis. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. The Compliance Officer observed E1 and E2 providing services to the resident during the inspection.  2. A review of the facility’s September 2025 personnel schedule revealed the following:  E1 was not listed on the schedule for September 2025. E2 was scheduled for every day except September 7, 14, 21, and 28.  3. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB.  4. A review of E2's personnel record revealed E2’s hire date of November 30, 2013. The personnel record revealed no documentation of training and education related to recognizing the signs and symptoms of TB.  5. A review of the facility’s documentation revealed no annual assessment of the facility's TB risk assessment.   6. In an interview, E2 acknowledged that an assessment of the health care institution's risk of exposure to infectious TB was not conducted, nor was the employee's annual training.  7. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 8. Technical assistance was provided on this Rule during the compliance inspection on July 13, 2023.”

“Based on observation, record review, documentation 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 one of three employees reviewed. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. The Compliance Officer observed E1 providing services to the resident during the inspection.   2. A review of E1's personnel record revealed E1’s hire date of September 1, 2025. However, the record revealed no documentation showing E1 had received orientation specific to the duties to be performed.   3. A review of the facility’s policies and procedures revealed a policy titled "Applicant and Employee Requirement" (dated January 13, 2023). The policy and procedure stated "...After the employee is hired by this facility, ...the new employee completes the New Employee Orientation within 10 days from the employee's date of hire ..." 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection conducted on July 13, 2023.”

“Based on documentation review, observation, and interview, the manager failed to ensure a resident's medical record was protected from loss, damage, or unauthorized use. The deficient practice posed a risk of protected and sensitive resident health information being disclosed without the resident's consent or knowledge.  Findings include: 1. A.R.S. § 12-2291(6) "Medical records" means all communications related to a patient's physical or mental health or condition that are recorded in any form or medium and that are maintained for purposes of patient diagnosis or treatment, including medical records that are prepared by a health care provider or by other providers. 2. The Compliance Officers observed residents’ medical records sitting on a bookshelf on the desk in plain sight. The bookshelf, where the medical records were stored, had no doors to lock up the records. The office was near the front door, towards the left as you walked in. The office was an open space that had a clear path to the living room and dining room.  3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”

“Based on observation, documentation review, and interview, the manager failed to ensure that an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan and the Department was provided false or misleading documentation. Findings include: 1. During the inspection, the Compliance Officer (CO) heard the printer printing. The CO went to the kitchen and found E2 printing documents. E2 had filled out three different pages prior to the CO questioning E2. The CO observed the title on one of the pages stated disaster drill. 2. In an interview, E2 acknowledged that E2 was filling out the disaster drill pages.       3. A review of the facility's documentation revealed the following:  A disaster plan was filled out for August 5, 2025, and signed by E2. This was one of the documents that the CO saw E2 filling out.  A disaster plan was conducted on May 5, 2025, at 9:00 am, 3:00 pm, and 7:00 pm, which was signed by E3. A disaster plan was conducted on February 5, 2025, at 9:00 am, 3:00 pm, and 7:00 pm, which was signed by E3. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.”