Haven of Show Low Alf, LLC.

“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 one of three residents sampled.   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 medical record revealed a negative skin test, but no signs and symptoms, and risk assessment. Based on the resident's date of acceptance, this documentation was required. 3. A review of R3's medical record revealed a negative skin test, but no signs and symptoms, and risk assessment. Based on the resident's date of acceptance, this documentation was required. 4. In an interview, E1 acknowledged that R1 and R3 did not have proper documentation of freedom from infectious tuberculosis as specified in R9-10-113.”

“Based on documentation review and interview, for a facility authorized to provide directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outdoor area and controlled or alerted employees to a resident’s egress.   Findings include:   1. A review of Department records revealed the facility was licensed to provide Directed Care Services.   2. The Compliance Officer observed multiple ambulatory residents. 3. During an environmental inspection of the facility, the Compliance Officer observed a resident walk through a door leading to the courtyard area. The door had no alert or monitoring in place. The courtyard also had another door that led to the skills nursing side, which also had no alert or monitoring in place. 4. In an interview, E1 acknowledged that the doors leading to the courtyard had no way of alerting caregivers of a resident's egress.”

“Based on documentation review and interview the manager failed to ensure that policies and procedures were reviewed at least once every three years. Findings include: 1. Review of the facility policy and procedure manual revealed documentation indicating that the manual had been created in 2016. However, the signature of the manager was not dated therefore, it could not be determined when the policies and procedures had been reviewed. No additional documentation indicating that the policies and procedures had been reviewed at least once every three years was available for review. 2. During an interview, E1 acknowledged that the required documentation was not available for review.”

“Based on record review and interview, the manager failed to ensure for one of three sample records that before providing personal care services or directed care services to a resident, a manager or caregiver provides documentation of first aid training and cardiopulmonary resuscitation (CPR) training certification specific to adults. Findings include: 1. The record for E1 (hired August 21, 2019), failed to reveal documentation of current CPR and First aid certifications. 2. During an interview, E1 acknowledged that the employee provided services to residents without current documentation of first aid and CPR training certification.”

“Based on record review and interview, the manager failed to ensure that one of four sample resident records had a written service plan that was reviewed and updated at least once every 12 months for a resident receiving supervisory care services. Findings include: 1. The record for R4 revealed that the last service plan review was dated November 5, 2021. 2. During an interview, E1 acknowledged the service plan documentation did not reflect that the plan was reviewed and updated at least once every twelve months.”

“Based on documentation review and interview, the manager failed to ensure that daily social, recreational, or rehabilitative activities are planned. Findings include: 1. Review of 12 months of activity calendars revealed that during the months of September and October 2023, no activities noted for Saturdays and Sundays. 2. During an interview E1 acknowledged the required documentation was not available.”

“Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and maintained for 12 months after the date of the evacuation drill that included an identification of residents needing assistance for evacuation. Findings include: 1. Review of 12 months of facility evacuation drill documentation revealed that the documentation failed to identify the residents needing assistance for evacuation. 2. During an interview, E1 stated, "We do have residents here who would need assistance." 3. During an interview, E1 acknowledged the required documentation was not available for review.”

“Based on record review, documentation review and interview, the manager failed to ensure that when a resident has an emergency that results in the resident needing medical services, a caregiver documents the emergency as per subsections a. through f. of this rule. Findings include: 1. Review of the record for R1 revealed that on May 21, 2023 the resident experienced a medical emergency that required immediate medical services. Documentation of the incident as required, was not available for review. 2. During an interview, E1 acknowledged the required documentation was not available for review.”

“Based on documentation review and interview, the manager failed to ensure that a fire inspection was conducted by the local fire department or the State Fire Marshal according to the time-frame established by the local fire department or the State Fire Marshal. Findings include: 1. Facility documentation indicated the last fire inspection was conducted by the local fire department on October 26, 2022. 2. During an interview with a representative from the local Fire Department it was determined that fire inspections are required on an annual basis. 3. During an interview, E1 acknowledged that the required documentation was not available for review.”