Family Loving Kare S1.

“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 for one of two personnel sampled.  Findings Include: 1. A review of the facilities Policies and Procedures revealed a policy labeled “FLK Fall Precautions” which indicated all employees must complete fall prevention and recovery training upon hire and annually thereafter. The policy included training materials which covered preventative measures to reduce falls and staff procedures “post fall”.  2. A review of E2’s personnel record revealed that documentation of initial fall prevention and fall recovery training upon hire and annually thereafter was not available for review. 3. In an interview, E1 acknowledged there was no documentation for E2 indicating E2 completed initial fall prevention and recovery training upon hire or annual fall prevention and recovery training thereafter.  4. In an exit interview, the findings were reviewed with E1 and no further information was provided.”

“Based on record review and interview, the health care institution failed to provide annual training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by or providing volunteer services for the health care institution, for one of two employees sampled.  Findings include:  1. A review of E2's personnel record revealed no documentation of annual TB training. E2 had no documented annual TB training for 2022, 2023, 2024, or 2025. Based on E2's date of hire, this documentation was required. 2. In an interview, E1 acknowledged E2’s record did not provide documentation in compliance with R9-10-113.  3. In an exit interview, the findings were reviewed with E1 and no further information was provided.”

“Based on documentation review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.     A.R.S. § 36-411 states:   "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459."   Findings Include: 1. A review of E2's personnel record revealed E2 had been hired as a Manager on February 14, 2012. 2. A review of E2's personnel record revealed verification of E2's fingerprint clearance card status was not available for review. 3. A review of E2's personnel record revealed verification that E2 was not on the adult protective services registry was not available for review. 4. In an interview, E1 stated they must have forgotten to verify E2's fingerprint clearance card and APS registry. 5. In an exit interview, the findings were reviewed with E1 and no further information was provided.”

“Based on documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees.   Findings include: 1. A review of facility documentation revealed a policy and procedure manual, however, documentation to indicate that the policies and procedures were reviewed at least once every three years and updated as needed was not available for review.  2. In an interview, E1 acknowledged that documentation to indicate the policies and procedures were reviewed at least once every three years and updated as needed was not available for review.  3. In an exit interview, the findings were reviewed with E1 and no further information was provided.”

“Based on documentation review, observation, and interview, the manager failed to ensure the premises and equipment used at the assisted living facility were free from a condition or situation that may cause a resident or other individual to suffer physical injury. The deficient practice posed potential elopement dangers to residents. Findings include: 1. A review of documentation revealed this facility is licensed for directed care residents. 2. A review of documentation revealed R2, and R3 are receiving directed care services from the facility. 3. The Compliance Officer observed the backyard was accessible to residents. The Compliance Officer observed a wall surrounding the backyard. The Compliance Officer observed a gate. The Compliance Officer noticed the gate did not have a lock on it. The lock was sitting on top of the wall where the gate was attached. The Compliance Officer was able to open the gate and access a driveway, desert, and surrounding neighborhood. 4. In an interview, E1 was unaware the gate in the backyard which led into a driveway, desert, and surrounding neighborhood had been left unlocked.”

“Based on documentation review, observation, and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area and were inaccessible to residents. The deficient practice posed a risk to the health and safety of a resident. Findings include: 1. A review of documentation revealed this home is licensed for directed care services. 2. The Compliance Officer observed in the kitchen under the kitchen sink were the following unlocked toxic and poisonous materials that was accessible to residents: - "Dawn" Platinum Advanced Power dishwasher liquid; and - "Cascade" Platinum liquid pods. 3. The Compliance Officer observed the backyard was accessible to residents. Sitting beside the swimming pools filtrations unit, and not locked up was the following toxic and poisonous material that was accessible to residents: - "Pool Season" 25 lbs bucket of Chlorinating Tablets. "Danger" was written in large print. 4. In an interview, E2 acknowledged poisonous and toxic materials stored by the assisted living facility were not in a locked area and were inaccessible to residents.”