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“Based on the record review and interview, the manager failed to ensure that the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery, which included both initial training and continued competency training for two of the three personnel sampled. The deficient practice posed a health and safety risk for residents.   Findings include:   1. A review of E2's and E3's personnel records revealed that no documentation of fall prevention and fall recovery training was available for the Compliance Officer to review.   2. In an interview, E1 acknowledged that the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included initial and continued competency training.”

“Based on record review and interview, the manager failed to ensure that for three of three residents sampled, a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for each resident. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's, R2's, and R3's medical records revealed they did not contain the completed emergency responder patient information documentation required in Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). 2. In an interview, E2 acknowledged the information required in A.R.S. \'a7 36-420.04 was not prepared in a standardized emergency responder patient information form as required.”

“Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, upon acceptance or upon the onset of the condition and every six months thereafter, stating the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed a service plan dated December 15, 2023. The service plan reported R2 was non-ambulatory and bed bound and required total assistance with bathing, dressing, and grooming. 2. A review of R2's medical record revealed documentation was not available stating R2's needs could be met by the facility and R2's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E2 reported R2 was not non-ambulatory upon admission, but had been non-ambulatory for approximately the last two years. E2 acknowledged R2's medical practitioner did not provide a written determination at least once every six months.”

“Based on documentation review, record review, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record for one of three residents sampled. The deficient practice posed a risk of a potential adverse reaction or outcome with an error in administering a resident's medication. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medication Administration Record." The policy stated, "A medication administration record shall be maintained for each resident receiving medication administration that includes: a. Name of resident b. Name of medication, dosage, directions, and route of administration c. Date and time of actual assistance in medication administration d. Signature and initials of the staff member providing medication administration e. Allergies." 2. A review of R1's medical record revealed a service plan dated October 10, 2023. The service plan revealed R1 received medication administration. 3. A review of R1's medical record revealed a signed medication order dated December 15, 2023 for Haloperidol 2 milligrams (mg), one tablet every six hours as needed for hallucinations. 4. A review of R1's medication administration record (MAR) for December 2023 revealed R1 received Haloperidol daily from December 16, 2023-December 31, 2023. According to the MAR, R1 also received a second dose of Haloperidol on December 29, 2023 and December 30, 2023. However, documentation of the times Haloperidol was administered was documented only on: -December 16, 2023 at 9:00 AM; and -December 17, 2023 at 8:00 AM. No additional documentation of the times R1 received medication administration of Haloperidol was documented on the December 2023 MAR. 5. A review of R1's MAR for January 2024 revealed R1 received medication administration of Haloperidol twice daily from January 1, 2024-January 9, 2024, and once on January 10, 2024. However, documentation of the times Haloperidol was administered was documented only on: -January 1, 2024 at 11:00 AM; -January 2, 2024 at 9:00 AM; -January 3, 2024 at 9:00 AM; -January 4, 2024 at 10:00 AM; -January 4, 2024 at 2:00 AM; -January 7, 2024 at 11:00 AM; -January 8, 2024 at 9:00 AM; and -January 9, 2024 at 8:45 AM. No additional documentation of the times R1 received medication administration of Haloperidol was documented on the January 2024 MAR. 6. A review of R1's medical record revealed a signed medication order dated November 7, 2023 for Lorazepam 0.5 mg, one tablet every two hours as needed for anxiety/agitation. 7. A review of R1's MAR for December 2023 revealed R1 received Lorazepam daily from December 16, 2023-December 31, 2023. R1 also received a second dose of Lorazepam on December 20, 2023 and December 29, 2023-December 31, 2023. However, no additional documentation of the times R1 received medication administration of Lorazepam was documented on the December 2023 MAR. 8. A review of R1's MAR for January 2024 revealed R1 received medication administration of Lorazepam twice daily from January 1, 2024-January 9, 2024, and once on January 10, 2024. However, documentation of the times Lorazepam was administered was documented only on: -January 1, 2024 at 9:00 AM; -January 1, 2024 at 2:00 PM; -January 2, 2024 at 8:00 AM; -January 3, 2024 at 11:00 AM; -January 4, 2024 at 8:00 AM; -January 4, 2024 at 12:00 PM; -January 7, 2024 at 9:00 AM; -January 7, 2024 at 2:00 PM; -January 8, 2024 at 7:45 AM; and -January 9, 2024 at 7:30 AM. No additional documentation of the times R1 received medication administration of Lorazepam was documented on the January 2024 MAR. 9. In an interview, E2 acknowledged medication administration provided to R1 was not consistently documented in R1's medical record as required.”

“Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of first aid training, for one of two caregivers 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 E2's personnel record revealed E3 was hired December 1, 2023 as a caregiver. 2. A review of the facility's policies and procedures (dated October 1, 2022) revealed a policy that stated, " ... 1. The manager and all care givers must have a valid current CPR and First Aid card to work with residents ... 3. Manager will check cards monthly and notify employees when cards need to be updated. Manager will then collaborate with employee and certified instructor to set up a date to renew card before it expires." 3. A review of E2's personnel record revealed documentation of expired first aid training dated January 2020-January 2022. Further review of E2's personnel record revealed current first aid training dated 4/16/2024-April 2026. There was no documentation of first aid from January 2022 to April 16, 2024. 4. A review of the facility's daily staffing schedule for April 2024 revealed E2 was scheduled to work alone on the following days at the times, prior to receiving current first aid training: -April 1, 2024; 6:00 PM-8:00 AM; -April 7, 2024; 6:00 PM-8:00 AM; -April 8, 2024; 8:00 PM-8:00 AM; -April 13, 2024; 8:00 PM-8:00 AM; -April 14, 2024; 6:00 PM-8:00 AM; and -April 15, 2024; 6:00 PM-8:00 AM. 5. In an interview, E1 acknowledged E2 did not have current first aid training prior to April 16, 2024. E1 stated E1 "overlooked it."”

“Based on observation, documentation review, and interview, the manager failed to ensure meals provided by the assisted living facility were served according to posted menus. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. The Compliance Officer observed menus for April 2024 posted in the kitchen on the refrigerator. 2. The Compliance Officer observed the menu labeled April 21st to April 27th. The menu listed Monday's breakfast as follows: Waffles, eggs, bacon, cream of wheat, orange or apple juice, and coffee. 3. A review of facility documentation revealed a policy and procedure titled "Meal Planning" (dated October 1, 2022). The policy stated " ... 2. Menus will be prepared in advance for seven days beginning on Sunday of each week using The Food Guide Pyramid. 3. Any substitution on the menu will be noted on the menu." 4. In an interview, R1 reported R1 had cereal for breakfast on the morning of April 22, 2024. 5. In an interview, E1 acknowledged meals provided by the assisted living facility were not served according to posted menus. E1 reported E1 would ensure substitutions are documented going forward.”

“Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training, including a demonstration of the individual's ability to perform CPR and documentation of current CPR training, for one of five personnel sampled. The deficient practice posed a risk to health and safety if E3 was unable to assist a resident in an emergency. Findings include: 1. A review of the facility's polices and procedures (reviewed and approved October 1, 2022) revealed a document titled, "CPR & First Aid Policy and Procedure" which stated, "To ensure all staff is properly trained in First Aid and CPR by an accredited instructor from Red Cross, American Heart Association and or the American Safety & Health Institute. The CPR program must use mannequins for demonstration. All employees and volunteers who work with the residents must have a valid and current CPR and First Aid card prior to hire." 2. A review of E3's personnel record revealed current documentation of E3's CPR training from the "National CPR Foundation," dated February 15, 2022. However, the CPR training did not include a hands-on demonstration of techniques. 3. In an interview, E2 acknowledged E3's personnel record included CPR training without hands-on demonstration as required.”