Ageless Angels Alh 2

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort that provided access to an outside area that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of the facility license revealed the facility was licensed at the directed care level. 2. The Compliance Officer also observed an unlocked door in the bedroom of R2 and R3 that led to the backyard of the facility. The door did not have an alarm or any form of a monitoring system. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review, documentation review and interview, the manager failed to ensure that a personnel record for each employee included initial training and continued competency training in fall prevention and fall recovery for two of two employees sampled. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings Include: 1. A review of E1’s personnel record revealed no documentation of fall prevention and recovery training before hire and no fall prevention and recovery training 12 months after their latest training. E1's latest fall prevention and recovery training was completed March 14, 2024. 2. A review of E2’s personnel record revealed no documentation of fall prevention and recovery training before hire and no fall prevention and recovery training 12 months after their latest training. E2's latest fall prevention and recovery training was completed March 14, 2024. 3. A review of the facility’s policies and procedures revealed a document titled "Fall Prevention and Recovery" with the following verbiage, "Fall Prevention and Recovery Training is required upon hire and at least 12 months thereafter." 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the health care institution 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, for two of two employees sampled. Findings include: 1. A review of E1's personnel record revealed training and education related to recognizing the signs and symptoms of tuberculosis, completed March 23, 2024. No current documentation was available. 2. A review of E2's personnel records revealed no documentation of training and education related to recognizing the signs and symptoms of tuberculosis. 3. A review of the facility's documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis. 4. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure compliance with A.R.S. § 36-411, for two of two employees sampled. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A review of A.R.S. § 36-411 states "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 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." 2. A review of E1 and E2's personnel records revealed no documentation that E1 and E2 were not on the adult protective services registry. 3. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on interview, record review, and documentation review, the manager failed to ensure a caregiver provided documentation of completing a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of two caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services. Findings include: 1. In an interview, E3 and E4 reported E2 worked as a caregiver. E3 and E4 reported E2 administered medication and assisted with resident care. 2. A review of E2's personnel record revealed an employment application that indicated E2 worked as a caregiver. 3. A review of the personnel schedule dated October 2025 revealed E2 was not listed on the schedule. 4. A review of the R1 and R2's October 2025 medication administration records revealed E2 administered medication to both residents. 5. A review of E2's personnel record revealed no documentation of a completed caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers was available. 6. A review of the https://azcg.tmutest.com/search website revealed no documentation of a caregiver training certificate for E2. 7. A review of the facility's policies and procedures revealed a document titled, "Employees and Volunteers Qualifications," with the following verbiage "Procedures: The hiring individual or manager shall hire at least one certified caregiver per shift and assistant caregivers and volunteers to provide duties as instructed in order to cover the scheduled and unscheduled needs of the residents. A caregiver: Is 18 years of age or older, and provides documentation of completion of a caregiver training program approved by the Department or by the NCIA Board..." 8. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a service plan, for one out of two residents sampled. The deficient practice posed a risk as there was no service plan to direct services to be provided to a resident. Findings include: 1. A review of R2's medical record revealed no documentation of a service plan. Based on R2's date of acceptance, this documentation was required. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order for one of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a September and October 2025 medication administration records(MAR) that showed the following: Cilopirox, 8%, apply every night, and indicated the medication was administered at 8pm every night October 1-20; Tramadol 50mg 1 tab po, every six hours as needed for pain, and indicated the medication was last administered September 30, 2025, time not recorded; and Clotrimazole cream, 1%, apply two times a day, and indicated the medication was administered at 8am and at 8pm October 1-20. 2. A review of R1's medical record revealed no documentation of signed medication orders for Cilopirox, 8%, Tramadol 50mg, or Clotrimazole cream 1%. 3. In an observation of R1's medications, Cilopirox 8%, Tramadol 50mg, and Clotrimazole cream 1% were observed. 4. In an interview, E3 reported the medications were administered per the MAR. 5. The findings were reviewed with E3 and no additional information was provided.

Based on 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 two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R2's medical record revealed signed medication orders dated for August 25, 2025. The medication order stated "Antifungal Powder, apply to groin/... two times a day, and leave groin open to air during the day. However, no documentation of administration for this medication was available. 2. In an exit interview, the findings were reviewed with E3 and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of notification of the availability of the vaccinations for influenza (flu) and pneumonia according to A.R.S. \'a7 36-406(1)(d), which required the facility to make the vaccinations available to a resident on site on a yearly basis; for three of four sampled residents records reviewed who had resided at the assisted living facility for more than 12 months, which posed a health and safety risk. Findings include: 1. Based on the dates of acceptance, R2's, R3's, and R5's medical records did not contain documentation to indicate these three sampled residents had received the flu and pneumonia vaccines as required. There was no other documentation available in their medical records to indicate the vaccines had been offered, given, refused, or contraindicated within the past 12 months. 2. In an interview, E1 acknowledged there was no documentation available that these sampled residents had received the flu and pneumonia vaccines or the vaccines had been made available to these residents during the past 12 months.

Based on record review and interview, the manager failed to ensure a resident's orientation to the exits from the assisted living facility and the route to be used when evacuating the assisted living facility was completed within 24 hours after the resident's acceptance by the facility and documented; for one of one sampled resident's records reviewed, which posed a safety risk. Findings include: 1. Review of R1's record, based on their date of acceptance, revealed there was no documentation indicating the sampled resident received orientation to the exits from the facility and the route to be used when evacuating the facility within 24 hours after the resident was accepted by the facility. 2. During an interview, E2 acknowledged there was no documentation to indicate the sampled resident had received evacuation orientation to the exits from the facility within 24 hours after the residents' acceptance, nor anytime since.