Arizona State Veteran Home - Flagstaff

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. Findings include: A review of the personnel file for the Activities Director (staff #14) revealed staff #14was hired on September 16, 2024. Further review of staff #14's personnel file did not reveal any documentation that she is a certified therapeutic recreation specialist, activities professional, or a qualified occupational therapist or occupational therapy assistant. A letter of employment offer dated September 16, 2024 indicated that staff #14 was hired as the facility's Therapeutic Program Manager. Review of the position description form for Therapeutic Program Manager indicated the position manages and supervises a program of therapeutic recreation services for the facility. Responsibilities includes the design, planning, organizing, implementation, and evaluation of the program. The position function includes to ensure services are delivered in compliance with facility policies and procedures as well as state and federal regulations. The licenses and certification portion of the position requirements included a bachelor's degree in Therapeutic Recreation or related filed, certification as a Recreation Therapist or credentialed as a Certified Occupational Therapist Assistant, obtain and retain a fingerprint clearance card. A review of the facility's Staff Directory revealed that staff #14 is listed as the Activities Director. Furthermore, review of the facility's organization chart indicated that the Therapeutic Program Manager reports directly to the Administrator. The organization chart also revealed that there are 4 recreational therapist that reports directly to the Therapeutic Program Manager. A signed memo by the Administrator (staff #7) dated January 28, 2025 stated that staff #14 is currently enrolled in a certification program to be a certified activity professional. The memo also indicated that the facility does not have a certified Activities Director. The Activities Director (Therapeutic Program Manager/staff #14) was not in the facility on January 28, 2025 and was not available for an interview. An interview with the Administrator (staff #7) was conducted on January 28, 2025 at 3:56 p.m. Staff #7 stated that the importance of having qualified and adequately trained staff is to ensure that the staff is able to provide the minimum expected care. The Administrator said that the impact of not having qualified staff is that it could cause problems. Furthermore, staff #7 noted that it might lead to not providing the minimum acceptable care. The Administrator indicated that his expectation is that all staff have the things that are required for their position. The facility policy titled "Hiring" revised January 2008 indicated that among the criteria used to determine that an applicant is qualified for a position are: certification/licenses, skill

Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored safely and according to facility policy within the facility refrigerators and dry goods storage. The deficient practice could result in the spread of foodborne illness. Findings include: An observation was conducted on January 28, 2025, at 11:19 AM in the facility's kitchen. The following items were observed in the facility refrigerator: -Pie filler with a date marked January 18 and no use by date indicated. -A container of chopped green chilies with a use by date marked January 25, 2025. -A box of green peppers with multiple peppers noted to be wrinkly and blackened. In the facility dry goods storage area, the following items were observed: -A bulk bin containing all-purpose flour, with no opened or use by date -A bulk bin containing cane sugar, with no opened or use by date -An open to air / unsecured bag of vanilla wafers with an opened date marked November 30. An interview was conducted with the Dietary Manager (Staff #29) at this time. Staff #29 stated that "it is open" in regard to the open bag of vanilla wafers, and that items in the refrigerator should be disposed of by the use by date. A follow-up observation was conducted in the kitchen on January 28, 2025, at 3:13 PM. In the facility refrigerator was observed: -The pie filler was no longer present. -The chopped green chilies were no longer present. -The box of green peppers was still present, and observed that multiple peppers were wrinkly and blackened. The follow-up observation continued in the dry goods storage area, and the following was observed: -The bulk bin containing all-purpose flour, still present with no opened or use by date -The bulk bin containing cane sugar, still present with no opened or use by date -The bag of vanilla wafers was still present, but the open top of the bag had been rolled down. An additional interview was conducted with the Dietary Manager (Staff #29) at this time. In regard to the box of wrinkly and blackened peppers, Staff #29 stated that the peppers were "old and moldy" and "we're going to toss that box". Staff #29 stated that it is important to label and store food properly to make sure the food is safe to eat and to prevent food poisoning. An interview was conducted on January 28, 2025, at 3:56 PM, with the Administrator (Staff #7), who stated that it was the facility's expectation for staff to properly handle and store food, and that the facility follows policies and county rules. The Administrator stated that an impact on residents if food is not properly dated or stored could be sickness and possible death. Review of the facility policy titled Food Receiving and Storage, dated 2001, revealed that food shall be received and stored in a manner that complies with safe food handling practices. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. Additionally, dry foods