Vandermeyer Senior Homecare LLC.

“Based on documentation review, record review, and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if a staff member was not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of facility documentation revealed a policy and procedure (P&P) titled "Fall Prevention and Recovery." The P&P stated, "Fall Prevention and Recovery Training is required upon hire and at least every 12 months thereafter." 2. A review of E2's personnel record revealed E2 was hired as a caregiver. The review revealed documentation demonstrating E2 received training regarding fall prevention and fall recovery on October 3, 2022; November 2, 2023; and November 1, 2024. The review revealed E3 did not receive the training within 12 months of October 3, 2022. 3. In an interview, E1 acknowledged E2 did not receive fall prevention and fall recovery training within 12 months of October 3, 2022, as required by facility P&Ps.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(C), for one of three sampled employees. The deficient practice posed a risk if the employees were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(4) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459.” 2. A review of E2's personnel record revealed E2 was hired before March 31, 2025. However, the review revealed no documentation demonstrating compliance with A.R.S. § 36-411(C)(4). 3. A review of the Adult Protective Services (APS) registry website revealed E2 was not on the registry. 4. In an interview, E1 stated, “I didn’t do it for [E2].””

“Based on record review, documentation review, and interview, the manager failed to ensure a caregiver provided current documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults before providing assisted living services to a resident, for one of two sampled caregivers. The deficient practice posed a risk if a caregiver was unable to meet a resident's needs during an emergency and the Department was provided false or misleading information. Findings include: 1. A review of E3’s personnel record revealed E3 was hired as a caregiver. The review revealed documentation of first aid training and CPR training certification specific to adults originally dated as issued on February 23, 2022, and expired on February 23, 2024. However, the “Class Completion Date” was changed from “2022” to “2023” and the “Expiration Date” was changed from “2024” to “2025.” The review revealed current first aid training and CPR training certification dated as issued on January 20, 2025. The review further revealed E3 did not have current first aid training and CPR training certification between February 23, 2024, and January 20, 2025. 2. A review of facility documentation revealed a series of personnel schedules which indicated E3 worked on a regular basis between October 2024 and January 2025. 3. In an interview, E1 reported E3 had mentioned E3’s first aid training and CPR training certification had expired. E1 showed the Compliance Officer a series of text messages between E1 and E3 dated March 14, 2025. The messages included a picture of the expired certification and a text from E3 which stated: “Hi, good morning, that’s my [CPR] in first date but I looking at this expired. I’m gonna have the give me another one.””

“Based on documentation review, observation, and interview, the manager failed to ensure a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that monitored 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 egress of a resident from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed four egress doors with alerts installed. However, each of the four alerts were in the “OFF” position and did not sound when the Compliance Officer opened the doors. The Compliance Officer further observed no monitoring method present. 3. In an interview, E1 acknowledged the alerts had been turned off, stating, “We turned [them] off.””

“Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication. Findings include: 1. The Compliance Officer observed an unlocked closet door with the key in the lock. Inside the closet, the Compliance Officer observed a variety of resident medications. 2. In an interview, E1 reported the closet was used to store resident medications. Turning to another personnel member, E1 stated, “You left the med key in the door."”