Assisted Living at the Phoenician

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Falls Prevention and training program" dated January 3, 2020. The policy stated "...C. All caregivers and assistant caregivers shall undergo continued competency training/inservice on fall prevention and fall recovery once per year." 2. A review of E1's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery. 3. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery. 4. In an interview, E1 reported to be unaware of the requirement for E1 to have fall prevention and fall recovery training. E1 reported E3 did not complete fall prevention and fall recovery training. E1 acknowledged the facility had not administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat citation from the previous on-site compliance inspection conducted on May 16, 2022.

Based on record review, documentation review, and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover skills and knowledge for a manager. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of E1's personnel record revealed documentation of E1's verified skills and knowledge was not available for review. 2. A review of the facility's policies and procedures revealed a policy titled "Personnel Qualifications, Orientation, Training and Records" dated January 3, 2023. The policy stated "B. Manager Qualifications 1. Is 21 years of age or older. 2. Is certified by the Board of Examiners as an assisted living facility manager with a certificate issued under A.R.S. 36-446.04 (C)...B. Manager Job Description 1. Has the authority and responsibility to operate the assisted living facility. 2. Ability to handle admission and orientation of new residents. 3. Ability to work with care providers, caregivers, resident's family..." However, a policy and procedure to cover the required skills and knowledge for a manager was not available for review. 3. In an interview, E1 acknowledged a policy and procedure to cover the required skills and knowledge for a manager was not available for review.

Based on record review, documentation review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for one manager sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs. Findings include: 1. A review of E1's personnel record revealed documentation of E1's verified skills and knowledge was not available for review. 2. A review of the facility's policies and procedures revealed a policy titled "Personnel Qualifications, Orientation, Training and Records" dated January 3, 2023. The policy stated "B. Manager Qualifications 1. Is 21 years of age or older. 2. Is certified by the Board of Examiners as an assisted living facility manager with a certificate issued under A.R.S. 36-446.04 (C)...B. Manager Job Description 1. Has the authority and responsibility to operate the assisted living facility. 2. Ability to handle admission and orientation of new residents. 3. Ability to work with care providers, caregivers, resident's family..." However, a policy and procedure to cover the required skills and knowledge for a manager was not available for review. 3. In an interview, E1 acknowledged E1's personnel record did not include documentation of E1's skills and knowledge, applicable to E1's job duties.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed orientation, for two of three employees sampled. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-101(153) states "Orientation" means: "the initial instruction and information provided to an individual before the individual starts work or volunteer services in a health care institution." 2. A review of E1's personnel record revealed documentation of E1's completed orientation was not available for review. 3. A review of E3's personnel record revealed documentation of E3's completed orientation was not available for review. 4. A review of the facility's policies and procedures revealed a policy titled "Personnel Qualifications, Orientation, Training and Records" dated January 3, 2020. The policy stated "Employee Orientation:...2. All new employees will complete orientation within 10 days from the starting date of employment..." 5. In an interview E1 reported E3 had completed orientation, however, E1 could not locate the documnetation. E1 reported to be unaware of the requirement for E1 to have completed orientation. E1 acknowledged documentation of E1's and E3's completed orientation was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R2's medical record revealed an undated document titled "APPROVAL FOR ALF ADMISSION/RETENTION." The document stated "My patient does not need continuous medical services, continuous nursing services, or restraints." The document was signed and dated by a physician. However, the document was dated after R2's acceptance. 2. In an interview, E1 acknowledged the documentation was not submitted before or at the time of R2's acceptance. This is a repeat citation from the previous on-site compliance inspection conducted on May 16, 2022.

Based on documentation review, observation, and interview, the manager failed to ensure the premises was cleaned to prevent, minimize, and control illness or infection. The deficient practice posed a risk as cockroaches may carry and spread bacteria. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Pest Control" dated January 3, 2020. The policy stated "1. Introduction Pests pose a threat to the health and safety of our residents and employees. Assisted Living at the Phoenician's goal is to provide a safe and healthy environment that is free from pests and other health hazards." 2. A review of facility documentation revealed a pest control contract dated May 17, 2022. The contract stated "Service...Residential...Type Quarterly..." 3. A review of facility documentation revealed pest control invoices indicating pest control services were provided on November 16, 2022, February 15, 2023, April 5, 2023, and April 19, 2023. 4. During the environmental inspection of the facility, the Compliance Officer observed one small brown insect, appearing to be a live cockroach, in a hallway bathroom, and one small brown insect, also appearing to be a live cockroach, in the policy and procedure binder. The Compliance Officer also observed what appeared to be casings from insect eggs on the floor in the office area. 5. In an interview, E2 reported the insect observed in the hallway bathroom was a cockroach. 6. In an interview, E1 reported the facility is cleaned daily. E1 also called the contracted pest control company to start providing weekly pest control services. 7. In an interview, E1 acknowledged the premises was not sufficiently cleaned to prevent, minimize, and control illness or infection.