Assisted Living at the Woodridge, INC

Based on the record review and interview, the manager failed to ensure that the healthcare institution administered a training program for all staff regarding fall prevention and fall recovery, which included both initial training and continued competency training for two of the three personnel sampled. The deficient practice posed a health and safety risk for residents. Findings include: 1. A review of E2’s personnel records revealed documentation of Fall Prevention and Fall Recovery Training for 2024. However, no documentation of Initial Fall Prevention and Fall Recovery for 2025 was available for review. Based on E2’s hire date, this document is required. 2. A review of E3’s personnel records revealed documentation of Fall Prevention and Fall Recovery Training for 2025. However, no documentation of Initial Fall Prevention and Fall Recovery for 2024 was available for review. Based on E3’s hire date, this document is required. 3. In an interview, E2 acknowledged that the facility failed to administer a training program for staff regarding fall prevention and fall recovery that included Initial training.

Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411 for one of the three personnel sampled. The deficient practice posed a risk if E2 were a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411(C)(2) states, "Each residential care institution, nursing care institution, and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person’s fingerprint clearance card." 2. During the on-site compliance inspection, the Compliance Officers observed E2 at the facility, providing services to residents. 3. A review of E2's personnel record revealed documentation of a valid FPCC dated before E2's hire date. However, the records did not include documentation of the facility's verification of E2's FPCC. 4. In an interview, E2 acknowledged that E2's FPCC cards were not verified, and the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2).

Based on observation and interview, the manager failed to ensure there was a current toxicology reference guide that was available for use by personnel members. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer requested the current toxicology reference guide. However, the toxicology reference guide was not provided to the department for review. 2. In an interview, E2 acknowledged that the facility did not have a toxicology reference guide available for use by personnel members.

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 of three employees sampled. The deficient practice posed a risk if an employee was unable to meet a resident's needs. Findings include: 1. A review of E2's personnel record revealed E2 was hired as the manager of the facility. However, documentation of E2's verified skills and knowledge was not available for review. 2. A review of the facility's policies and procedures revealed 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 E2's personnel record did not include documentation of E2's skills and knowledge applicable to E2's job duties.

Based on record review and interview, the manager retained a resident who was confined to a bed or chair without meeting the requirements in Arizona Administrative Code (A.A.C.) R9-10-814(B)(2), at least once every six months throughout the duration of the resident's condition, for one of two residents sampled who were confined to a bed or chair because of an inability to ambulate even with assistance. Findings include: 1. A review of R2's medical record revealed a document titled "(Confined to a chair and uses a wheelchair for mobility)" dated and signed by a medical practitioner in December 2022. The document stated "Resident has been examined, and determined that the resident's needs can be met by the assisted living facility within the assisted living facility's scope of services..." However, R2's medical record did not include evidence of a determination signed and dated by the resident's primary care provider or other medical practitioner at least once every six months. 2. In an interview, E1 reported R2 was non-ambulatory upon admission to the facility. E1 acknowledged the examination required from the resident's primary care provider or other medical practitioner every six months during R2's residency was not available for review.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. The deficient practice posed a risk if the facility was unaware of a resident's general or specific whereabouts. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "DIRECTED CARE POLICY AND PROCEDURES (WANDERING POLICY)" dated July 11, 2022. The policy stated "The manager shall ensure that, when an assisted living facility is providing services to a resident who is unable to direct self care, the following will be provided...3. Alarms and door alarms to alert staff;" 2. A review of Department documentation revealed AL4974 was authorized to provide directed care services. 3. During the environmental inspection of the facility, the Compliance Officer observed a back door leading out to the back yard from the kitchen area. The Compliance Officer observed the outside area in the back yard allowed residents to be a least 30 feet away from the facility. The Compliance Officer observed the outside area contained one locked gate. The door leading to the outside area contain an alarm, however, the alarm was switched to "off" and did not control or alert employees of egress when the door leading out to the back yard was opened. 4. In an interview, E1 acknowledged the door leading to the outside area did not control or alert employees of the egress of a resident.