R & D Marathon Assisted Living Home III LLC.

“Based on documentation review, and interview, the governing authority failed to designate, in writing, an acting manager, if the manager was expected not to be present or was not present on the assisted living facility's premises for more than 30 calendar days. The deficient practice posed a risk to the health and safety of the residents as no individual was designated to act on behalf of the governing authority in the onsite management of the assisted living facility.   Findings include:   1. A review of the Department documents revealed E1 was appointed as the manager of the facility as of October 24, 2024.   2. During an interview, E2 reported that the "manager does not come to the facility often and has not been to the facility since before January".   3. During an interview, E4 reported E4 was unaware that E1 had not been to the facility since before January. E4 acknowledged the governing authority did not designate, in writing, an acting manager while E1 was away from the facility.”

“Based on documentation review, record review, and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for three of three resident records reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. A review of R1's, R2's, and R3's medical records revealed no documentation of screening for signs and symptoms of infectious TB. Based on R1's, R2's, and R3's acceptance dates, this documentation was required.  3. In an interview, E4 reported being aware of the TB screening requirements for residents. E4 acknowledged R1, R2, and R3 did not provide documentation of screening for signs and symptoms of infectious TB, as required in R9-10-113.”

“Based on record review and interview, the manager failed to ensure a resident had a written service plan which included services the resident was expected to receive, for one of three residents reviewed. The deficient practice posed a risk as the service plan reinforces and clarify services to be provided to a resident.   Findings include:   1. A review of R1's medical record revealed, no documentation of a written service plan. Based on R1's date of acceptance, this documentation was required.   2. In an interview, E4 reported that R1 went to the hospital and the staff must have put it in the paperwork that went with R1. E4 acknowledged that R1's record lacked documentation of a service plan.”

“Based on record review and interview, the manager failed to ensure a resident's orientation to the assisted living facility's evacuation plan and the route to be used was documented, for one of three residents reviewed.  Findings include:  1. A review of R1's medical record revealed no documentation indicating the resident received orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility.   2. In an interview, E4 reported all new residents received orientation to the exits from the assisted living facility as part of their move-in process. E1 acknowledged documentation was not available that showed R1 was oriented to the facility's evacuation plan.”

“Based on 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 E1's, E2's, and E3's personnel records revealed no documentation of fall prevention and fall recovery training.   2. In an interview, E4 acknowledged fall prevention and fall recovery training had not been conducted. This is a repeat deficiency from the inspection conducted October 23, 2024.”

“Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk if facility staff were not properly trained to assist a resident who had fallen and was unable to recover independently. Findings include: 1. A review of E1's personnel record revealed E1 did not have documentation of fall prevention and fall recovery training. 2. In an interview, E6 reviewed and acknowledged E1's record did not have documentation of fall prevention and fall recovery training.”

“Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five personnel sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Finding include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. A review of E2's personnel record revealed a fingerprint clearance card that expired on May 29, 2024. E2's record reflected E2's fingerprint was verified on July 1, 2024. 3. The compliance officer (CO) observed E2 to be the only licensed caregiver on-site upon the CO's arrival. 4. A review of the facility's schedule dated October 2024 revealed E2 was scheduled as a caregiver. 5. In an interview, E6 reviewed and acknowledged E2's record did not contain a valid fingerprint clearance card. E6 reported E2 would apply for a new one "Tomorrow".”

“Based on interview and documentation review, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident that cover methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center is authorized to provide. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer requested to review the facility's policy and procedure to cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide. However, E6 was unable to locate the aforementioned policy and procedure for review. 3. In an interview, E6 reviewed the facility's policy and procedures acknowledged this policy was not documented that covers the methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide.”

“Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving personal care services. Findings include: 1. During a facility tour with E1, the compliance officer observed resident bedrooms labeled "1" which contained R3, and bedroom labeled "7" which contained R2 , which did not have a bell, intercom, or other means to alert employees to needs or emergencies. The surveyor observed no other means to alert a caregiver to the residents needs. 2. A review of R2's and R3's medical records revealed R2 and R3 were personal level of care. 3. In an interview with E6, E1 acknowledged that bedrooms labeled "1", and "7" , which contained residents, did not have a bell, intercom, or other means to alert employees to needs or emergencies. 4. In an interview, E6 reported bells were the means used to alert employees of a resident's needs. E6 acknowledged during the tour, the above resident rooms did not have bells.”

“Based on observation, record review, and interview, the manager failed to ensure a bell, intercom, or other mechanical means to alert employees to a resident's needs or emergencies was available in a bedroom being used by a resident receiving directed care services. Findings include: 1. During a facility tour with E1, the compliance officer observed resident bedrooms labeled "4" which contained R4 did not have a bell, intercom, or other means to alert employees to needs or emergencies. The surveyor observed no other means to alert a caregiver to the resident's needs. 2. A review of R4's medical record revealed R4 was directed level of care. 3. In an interview with E6, E1 acknowledged that bedrooms labeled "4" which contained R4 did not have a bell, intercom, or other means to alert employees to needs or emergencies.”