Mountain Care of Snowflake, LLC.

“36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.”

“A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care;”

“A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;”

“R9-10-113. Tuberculosis Screening A. 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: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 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); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals em”

“Based on record review and interview the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. The training program shall include initial training and continued competency training as identified in facility training program documentation. Findings include: 1. Review of the record for E1 (hired April 4, 2022), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 2. Review of the record for E2 (hired May 21, 2023), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 3. Review of the record for E3 (hired April 28, 2021), failed to reveal that fall prevention and fall recovery continued competency training had been conducted on an ongoing basis. Documentation indicated that the last training had been conducted on August 3, 2023. 4. Review of the facility policy and procedure for fall prevention and fall recovery continued competency training indicated that training would be conducted upon hire and annually thereafter. 5. During an interview, E1 acknowledged that continued competency training for fall prevention and fall recovery had not been conducted as specified in policy and procedure.”

“Based on documentation review and interview, the manager failed to submit a documented report to the governing authority that included any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority that included an identification of each concern about the delivery of services related to resident care and any changes made or action taken as a result of the identification of a concern about the delivery of services related to resident care. 2. Review of the reports submitted to the governing authority revealed that the reports failed to include recommendations for changes regarding the concerns identified. 3. During an interview, E1 acknowledged that the required documentation was not included in the reports.”

“Based on record review and interview, the manager failed to ensure that one of three sample personnel records contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E2 (Manager Designee) contained documentation indicating that one TB test was administered within the 12 months prior to the date of hire. No other TB test documentation conducted within the past 12 months was found in the record. Based on the employee's date of hire this documentation would be required. 2. During an interview, E1 acknowledged that the employee worked more than eight hours per week and the documentation did not reflect that the employee records contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.”

“Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that include the information found in subsections a. through f. of this rule. Findings include: 1. Review of facility documentation failed to reveal information indicating that the health care institution had established and documented tuberculosis infection control documentation and activities that include subsections a. through f. of this rule . 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 that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually providing training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. Review of the record for E1 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 2. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 3. Review of the record for E3 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review. 4. During an interview, E1 acknowledge that the required documentation was not available.”

“Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1. Review of facility documentation failed to reveal an annual assessment of the health care institution's risk of exposure to infectious tuberculosis. 2. During an interview, E1 acknowledged that the required documentation was not available for review.”