Angel Wings Assisted Living, INC

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. Findings include: 1. Review of the record for E3 (hired January 31, 2024), failed to reveal documentation that fall prevention and fall recovery training had been administered. 2. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff. This is a repeat deficiency from the compliance inspection conducted on February 8, 2023.

Based on record review and interview, the manager failed to ensure that one of two sample personnel records, for personnel who work more than eight hours per week, contained evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113. Findings include: 1. The record for E3 (Assistant Caregiver) 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 employees record contained evidence of freedom from TB as specified in R9-10-113, prior to providing services to residents.

Based on record review and interview the manager failed to ensure that a record for one volunteer included all the information required in sub-sections a. through c. of this rule. Findings include: 1. During an interview, E1 indicated that O1 regularly volunteered at the facility. 2. No volunteer record was available for review. 3. During an interview, E1 acknowledged the required documentation was not available for review.

Based on observation and interview the manager failed to ensure that when medications were stored by the facility, the medications were stored in a locked area. Findings include: 1. Observation of the unlocked kitchen refrigerator revealed four containers of prescription eye drops belonging to R2. 2. During an interview, E1 acknowledged the medication was not stored in a locked area.

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 four of four 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. Review of the record for E4 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. 5. 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.