Ahwatukee Manor Assisted Living, LLC

Based on observation, documentation review, record review, and interview, the manager failed to ensure an employee had a valid fingerprint clearance card. Findings Include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 in the office behind a room divider sitting on a bed. 2. A review of facility documentation revealed a policy titled "Applicant and Employee Requirement Policy and Procedure" The policy stated "...Comply with fingerprinting requirements in ARS 36-411 (A) & (C) (copy of both sides of card required for employee file)." 3. A review of E3's personnel record revealed no documentation of compliance with the fingerprinting requirements in A.R.S. \'a7 36-411. 4. In an interview, R1 and R5 reported E3 provided direct health care services to residents without supervision at the facility. 5. In an interview E1 reported E3 (date of hire May 22, 2024) was the maintenance man and helped residents around the facility. E1 acknowledged E3 did not have documentation of compliance with the fingerprinting requirements in A.R.S. \'a7 36-411.

Based on observation, record review, and interview, the manager failed to ensure a caregiver had a valid caregiver training certificate. The deficient practice posed a risk as E2 was not qualified to provide the required services unsupervised. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E2 who was working at the facility with E4. The Compliance Officer observed E2 providing direct services to residents without supervision. 2. A review of facility documentation revealed a policy titled " Applicant and Employee Requirement Policy and Procedure "...\'b7 Be certified in the level of care services the Assisted Living Facility is licensed to provide (Supervisory, Personal, Directed, Behavioral Care, Behavioral Health Services) and provide Original certificate for verification, Copies to be made by facility." 3. A review of E2's personnel record revealed E2 was hired as a caregiver. There was documentation in E2's personnel record to indicate E2 completed an approved caregiver training program; however, when the Compliance Officer verified the caregiver certificate the date on the certificate was before the school was in operation. 4. In an interview, E1 acknowledged they never verified the caregiver certificate, and documentation for an approved caregiver training program for E2 was not provided to the Compliance Officer by the end of the inspection. E1 acknowledged E2 provided services to residents without having a valid caregiver training certificate.

Based on observation, documentation, record review and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the assistant caregiver provided physical health services to residents, for one of four sampled caregivers and assistant caregivers. The deficient practice posed a risk if employees did not have the skills and knowledge necessary to ensure the health and safety of residents. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed E3 in the office of the facility behind a room divider sitting on a bed. 2. A review of facility documentation revealed a policy titled " Applicant and Employee Requirement Policy and Procedure " The policy stated "... Verification of qualifications, knowledge, and skills to perform the duties of the job hired for." 3. A review of E3's personnel record revealed no documented verification of E3's skills and knowledge. The personnel record did not specify what position E3 was hired for at the facility. 4. In and interview, R2 and R5 reported E3 provides direct health care services to residents without supervision at the facility. 5. In an interview, E1 acknowledged E3's personnel record did not contain documented verification of skills and knowledge. 6. In an interview, E1 and E2 reported E3 was the spouse of E2 and helped out at the facility with maintenance and residents.

Based on documentation review and interview, the manager failed to ensure a resident was not subjected to restraint. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(201) states "restraint" means "any physical or chemical method of restricting a patient's freedom of movement, physical activity, or access to the patient's own body." 2. During the environmental inspection of the facility, the Compliance Officer observed bedrails on R1 bed. 3. A review of facility documentation revealed no documented report of the aforementioned incident. 4. In an interview, E1 reported E1 used the bedrails to keep R1 in the bed so R1 could not fall out of the bed.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a health and safety risk to residents with access to the poisonous or toxic materials. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed "Wizard Double Action 2in1 Air Freshener", "Scrubbing Bubbles Bathroom Grime Fighter", and "Roto Rooter Clog Remover" stored in the unlocked hallway bathroom cabinet which was accessible to residents. The hallway bathroom cabinet had a locking device installed, but the cabinet door was left unlocked at the time of the observation. 2. In an interview, E2 acknowledged the aforementioned poisonous or toxic materials were not stored in a locked location and inaccessible to residents at the time of the inspection.